Basic Information
| Provider Information | |||||||||
| NPI: | 1538263876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MARY LANNING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDGAR MEDICAL CLINIC | ||||||||
| 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: | 315 N C ST | ||||||||
| Address2: | |||||||||
| City: | EDGAR | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689353194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022243344 | ||||||||
| FaxNumber: | 4022243099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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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 | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 4058 | 01 | NE | STATE LICENSE-HHS | OTHER |