Basic Information
Provider Information | |||||||||
NPI: | 1619034253 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGH PLAINS MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAMS MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1625 DORWART DR | ||||||||
Address2: | PO BOX 379 | ||||||||
City: | SIDNEY | ||||||||
State: | NE | ||||||||
PostalCode: | 691622505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3082545544 | ||||||||
FaxNumber: | 3082542672 | ||||||||
Practice Location | |||||||||
Address1: | 562 VINCENT AVE. | ||||||||
Address2: |   | ||||||||
City: | CHAPPELL | ||||||||
State: | NE | ||||||||
PostalCode: | 69129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3088742255 | ||||||||
FaxNumber: | 3088742854 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 08/02/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRAUER | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDNET/CEO | ||||||||
AuthorizedOfficialTelephone: | 3082545544 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WESTERN NEBRASKA HEALTH SYSTEMS | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | 283861 | NE | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 10025499800 | 05 | NE |   | MEDICAID | CN7427 | 01 | NE | RR MEDICARE | OTHER | 10025511600 | 05 | NE |   | MEDICAID | 1945 | 01 | NE | BCBS | OTHER |