Provider Demographics
NPI:1760025191
Name:ANTELOPE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ANTELOPE MEMORIAL HOSPITAL
Other - Org Name:AMH FAMILY PRACTICE BCBS PCMH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUGGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-887-4151
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:NELIGH
Mailing Address - State:NE
Mailing Address - Zip Code:68756-0109
Mailing Address - Country:US
Mailing Address - Phone:402-887-5440
Mailing Address - Fax:402-887-4564
Practice Address - Street 1:109 W 11TH ST
Practice Address - Street 2:
Practice Address - City:NELIGH
Practice Address - State:NE
Practice Address - Zip Code:68756-1065
Practice Address - Country:US
Practice Address - Phone:402-887-5440
Practice Address - Fax:402-887-4564
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTELOPE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-17
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty