Provider Demographics
NPI:1265502538
Name:GOTHENBURG MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:GOTHENBURG MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-537-3661
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-0469
Mailing Address - Country:US
Mailing Address - Phone:308-537-3661
Mailing Address - Fax:308-537-3074
Practice Address - Street 1:910 20TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1253
Practice Address - Country:US
Practice Address - Phone:308-537-3661
Practice Address - Fax:307-537-3074
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOTHENBURG MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE220002275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28Z313Medicare Oscar/Certification