Basic Information
| Provider Information | |||||||||
| NPI: | 1497809966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRYAN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685061283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024815792 | ||||||||
| FaxNumber: | 4024814755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685061283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024815792 | ||||||||
| FaxNumber: | 4024814755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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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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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 101YP2500X | 500001 | NE | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TB0200X | 500001 | NE | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 1041C0700X | 500001 | NE | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 103TC1900X | 500001 | NE | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.