Basic Information
| Provider Information | |||||||||
| NPI: | 1033126107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCH PEDIATRIC CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1066 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025647200 | ||||||||
| FaxNumber: | 4025647210 | ||||||||
| Practice Location | |||||||||
| Address1: | 4508 38TH ST | ||||||||
| Address2: | STE 165 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025647200 | ||||||||
| FaxNumber: | 4025647210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4025647200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | DO FAAP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10025279800 | 05 | NE | MEDICAID |