Provider Demographics
NPI:1811021348
Name:FAMILY MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLSTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-284-8421
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-0026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 E 10TH ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-1425
Practice Address - Country:US
Practice Address - Phone:308-284-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NE098974FAMedicare ID - Type Unspecified
NE=========13Medicaid