Basic Information
| Provider Information | |||||||||
| NPI: | 1710064316 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGH PLAINS MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SIDNEY MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 1625 DORWART DR | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691622505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545544 | ||||||||
| FaxNumber: | 3082542672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRAUER | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/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 | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR1300X | 283860 | 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 | 10025499400 | 05 | NE | MEDICAID | 1945 | 01 | NE | BCBS | OTHER | CN7427 | 01 | NE | RR MEDICARE | OTHER |