Basic Information
| Provider Information | |||||||||
| NPI: | 1053515874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MARY LANNING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRAL NEBRASKA INFECTIOUS DISEASES CLINIC-MLMH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 N SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689014497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024634521 | ||||||||
| FaxNumber: | 4024615321 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N KANSAS AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689014438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024615358 | ||||||||
| FaxNumber: | 4024615368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4024615108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE MARY LANNING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | NE | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 10025523000 | 05 | NE | MEDICAID |