Basic Information
| Provider Information | |||||||||
| NPI: | 1134216773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRYAN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685061299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024815792 | ||||||||
| FaxNumber: | 4024814755 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 S 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024751011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | WOODRICH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & COO | ||||||||
| AuthorizedOfficialTelephone: | 4024813548 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRYAN MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 500003 | NE | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 611 | 01 | NE | BC/BS PROVIDER NUMBER | OTHER |