Basic Information
Provider Information | |||||||||
NPI: | 1578627196 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENDER COMMUNITY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENDER COMMUNITY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100 | ||||||||
Address2: |   | ||||||||
City: | PENDER | ||||||||
State: | NE | ||||||||
PostalCode: | 680470100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023854012 | ||||||||
FaxNumber: | 4023851870 | ||||||||
Practice Location | |||||||||
Address1: | 100 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | PENDER | ||||||||
State: | NE | ||||||||
PostalCode: | 680474507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023853083 | ||||||||
FaxNumber: | 4023851870 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2006 | ||||||||
LastUpdateDate: | 10/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAMBLE | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4023853083 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | H000120 | NE | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | H138 | 01 | NE | MIDLANDS CHOICE CAH HOSP | OTHER | 00140 | 01 | NE | BCBSNE CAH HOSPITAL | OTHER |