Basic Information
| Provider Information | |||||||||
| NPI: | 1376971036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENDER COMMUNITY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BANCROFT MEDICAL CLNIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100 | ||||||||
| Address2: | |||||||||
| City: | PENDER | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680470100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023854012 | ||||||||
| FaxNumber: | 4023851870 | ||||||||
| Practice Location | |||||||||
| Address1: | 219 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BANCROFT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680043021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026487606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2013 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAMBLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4023853083 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENDER COMMUNITY HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.