Provider Demographics
NPI:1841312584
Name:CENTRAL NEBRASKA MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:CENTRAL NEBRASKA MEDICAL CLINIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-872-2486
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:145 MEMORIAL DRIVE
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-0690
Mailing Address - Country:US
Mailing Address - Phone:308-872-2486
Mailing Address - Fax:308-872-2027
Practice Address - Street 1:706 MAIN ST.
Practice Address - Street 2:
Practice Address - City:ANSLEY
Practice Address - State:NE
Practice Address - Zip Code:68814-0706
Practice Address - Country:US
Practice Address - Phone:308-935-1367
Practice Address - Fax:308-872-2027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL NEBRASKA MEDICAL CLINIC, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28D0942874OtherCLIA NUMBER
NE=========13Medicaid
NE096394Medicare ID - Type UnspecifiedCENTRAL NEBRASKA MEDICAL