Provider Demographics
NPI:1699746248
Name:BRODSTONE MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:BRODSTONE MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREG
Authorized Official - Middle Name:
Authorized Official - Last Name:VYZOUREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-879-3281
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:NE
Mailing Address - Zip Code:68978-0407
Mailing Address - Country:US
Mailing Address - Phone:402-879-4781
Mailing Address - Fax:402-879-3365
Practice Address - Street 1:315 N C ST
Practice Address - Street 2:
Practice Address - City:EDGAR
Practice Address - State:NE
Practice Address - Zip Code:68935-3194
Practice Address - Country:US
Practice Address - Phone:402-224-3344
Practice Address - Fax:402-224-3346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRODSTONE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-31
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025359800Medicaid
NE10025288500Medicaid
NE10025288500Medicaid
NE09208Medicare ID - Type Unspecified