Provider Demographics
NPI:1669471801
Name:WESTERN FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:WESTERN FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-630-7977
Mailing Address - Street 1:PO BOX 1498
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69363-1498
Mailing Address - Country:US
Mailing Address - Phone:308-630-7977
Mailing Address - Fax:308-630-1028
Practice Address - Street 1:2 W 42ND STREET
Practice Address - Street 2:SUITE 2800
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4660
Practice Address - Country:US
Practice Address - Phone:308-630-7977
Practice Address - Fax:308-630-1028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026385500Medicaid
NE10026385500Medicaid
273252Medicare ID - Type Unspecified