Basic Information
| Provider Information | |||||||||
| NPI: | 1336155134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAH PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX N | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684460518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022692011 | ||||||||
| FaxNumber: | 4022692795 | ||||||||
| Practice Location | |||||||||
| Address1: | 2731 HEALTHCARE DR | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684467880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022692011 | ||||||||
| FaxNumber: | 4022692795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARVEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4022692011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CN4753 | 01 | NE | MEDICARE RAILROAD | OTHER | 8569 | 01 | NE | BCBS OF NEBRASKA | OTHER |