Provider Demographics
NPI:1457421471
Name:SURGERY GROUP OF GRAND ISLAND
Entity Type:Organization
Organization Name:SURGERY GROUP OF GRAND ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCMICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-398-8266
Mailing Address - Street 1:PO BOX 5226
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5226
Mailing Address - Country:US
Mailing Address - Phone:308-384-7200
Mailing Address - Fax:308-384-7378
Practice Address - Street 1:820 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4320
Practice Address - Country:US
Practice Address - Phone:308-384-7200
Practice Address - Fax:308-384-7378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NE98834Medicare PIN