Provider Demographics
NPI:1801867494
Name:PROVIDENCE MEDICAL CENTER
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-375-7954
Mailing Address - Street 1:1200 PROVIDENCE ROAD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1212
Mailing Address - Country:US
Mailing Address - Phone:402-375-7960
Mailing Address - Fax:402-375-7989
Practice Address - Street 1:1200 PROVIDENCE ROAD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1212
Practice Address - Country:US
Practice Address - Phone:402-375-7960
Practice Address - Fax:402-375-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE800001282NC0060X
NE282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE800001Medicaid
NE281345Medicare Oscar/Certification