Provider Demographics
NPI:1700055704
Name:BELLEVUE HEALTH AND EMERGENCY CLINIC, INC.
Entity Type:Organization
Organization Name:BELLEVUE HEALTH AND EMERGENCY CLINIC, INC.
Other - Org Name:BELLEVUE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:CARHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-292-4164
Mailing Address - Street 1:1002 W MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3947
Mailing Address - Country:US
Mailing Address - Phone:402-292-4164
Mailing Address - Fax:402-291-4643
Practice Address - Street 1:1002 W MISSION AVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3947
Practice Address - Country:US
Practice Address - Phone:402-292-4164
Practice Address - Fax:402-291-4643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15162207VG0400X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0996926Medicaid
NE=========00Medicaid
NE=========00Medicaid
087281Medicare PIN
IA0996926Medicaid