NPIMap

Organization Active NPI

Brodstone Memorial Hospital

Doing business as Brodstone Family Medical Center - Superior

  • Rural Health Clinic/Center
  • Superior, NE
National Provider Identifier
1073590626
Registry record updated Feb 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BRODSTONE MEMORIAL HOSPITAL
Doing business as
Brodstone Family Medical Center - Superior
Practice address
525 E 11TH St
Superior, NE 68978-1101
Phone
(402) 879-4781
Fax
(402) 879-3365
NPI assigned
Dec 26, 2005
Last updated
Feb 12, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
BRODSTONE MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 12, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Treg Vyzourek
Title
Ceo
Phone
(402) 879-3281

Specialties & licenses 11

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU
Endocrinology, Diabetes & Metabolism Physician 207RE0101X NU
Neurological Surgery Physician 207T00000X NU
Neurology Physician 2084N0400X NU
Vascular Neurology Physician 2084V0102X NU
Hospitalist Physician 208M00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU
Neurocritical Care Physician 2084A2900X NU

Addresses

Primary practice location

525 E 11TH St
Superior, NE 68978-1101

Mailing address

PO Box 407
Superior, NE 68978-0407
Phone (402) 879-4781

Other identifiers 1

IdentifierTypeStateIssuer
10025177900MedicaidNE

Other names 1

  • BRODSTONE FAMILY MEDICAL CENTER - SUPERIOR Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE, MO, TX, CA, KY, FL, NC, OK9 enrollments

Enrollment records 9

Enrollment IDStateProvider typePAC IDDetails
O20040423000949 NE Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 27 practitioners
3 other NPIs on this enrollment
Practice locations: Deshler, NE; Superior, NE
O20041020001386 NE Part A Provider - Rural Health Clinic 4082513015 Practice locations: Superior, NE
O20220531000719 MO Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 1 practitioner
Practice locations: Saint Joseph, MO
O20231011000203 TX Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 2 practitioners
Practice locations: Sugar Land, TX; Lewisville, TX
O20250214002165 CA Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 2 practitioners
Practice locations: Los Angeles, CA; Moraga, CA
O20250226002359 KY Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 2 practitioners
Practice locations: Louisville, KY; Prospect, KY
O20250307003454 FL Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 2 practitioners
Practice locations: Neptune Beach, FL
O20250317002677 NC Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 1 practitioner
Practice locations: Mint Hill, NC
O20250326000036 OK Part B Supplier - Clinic/Group Practice 4082513015 Receives reassigned benefits from 6 practitioners
Practice locations: Edmond, OK; Tulsa, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073590626. Details of each certification follow.

Rural health clinic certification: CCN 283478

Legal name
BRODSTONE MEMORIAL HOSPITAL
Doing business as
BRODSTONE FAMILY MEDICAL CENTER - SUPERIOR
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 1, 2004
Last certification
Mar 6, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Sep 24, 1926 in NE
Enrollment address
525 E 11TH St
Superior, NE 68978-1101
Related CCNs
281315

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
28D1027384Brodstone Family Medical Center - Superior525 East 11TH Street, Superior, NE 68978Certificate of waiverJun 28, 2028

National Provider Directory

National Provider Directory
Part of
Brodstone Mem Nuckolls Co

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Janet L Eggers Individual Corporate Officer Sep 24, 2018
Corporate Director May 22, 2017
Treg Vyzourek Individual Corporate OfficerCeo Jan 22, 2018
W-2 Managing EmployeeCeo Jan 22, 2018
Operational/Managerial ControlCeo Jan 22, 2018
Royce L Schott Individual Corporate Officer May 28, 2024
Corporate Director May 31, 2022
Piper a Hodge Individual Corporate Officer May 30, 2023
Corporate Director May 30, 2023
Judy a Baker Individual W-2 Managing EmployeeAd;Clinic Director Oct 1, 2002
Operational/Managerial ControlClinic Director Oct 1, 2002
Sandra Borden Individual Corporate Director May 28, 2024
Beth Siebecker Individual Corporate Officer May 25, 2021
Corporate Director Jul 30, 2018
Jacqueline Porter Individual Corporate Director May 23, 2016
Timothy D Blecha Individual W-2 Managing EmployeeMD; Oct 1, 2004
Operational/Managerial ControlMedical Director Oct 1, 2004

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 44

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 44

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135555200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739318400000",
    "number": "1073590626",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 407",
            "city": "SUPERIOR",
            "state": "NE",
            "postal_code": "689780407",
            "telephone_number": "402-879-4781",
            "fax_number": "402-879-3365"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "525 E 11TH ST",
            "city": "SUPERIOR",
            "state": "NE",
            "postal_code": "689781101",
            "telephone_number": "402-879-4781",
            "fax_number": "402-879-3365"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRODSTONE MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BRODSTONE MEMORIAL HOSPITAL",
        "enumeration_date": "2005-12-26",
        "last_updated": "2025-02-12",
        "certification_date": "2025-02-12",
        "status": "A",
        "authorized_official_last_name": "VYZOUREK",
        "authorized_official_first_name": "TREG",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "402-879-3281"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207T00000X",
            "taxonomy_group": "",
            "desc": "Neurological Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084V0102X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Vascular Neurology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084A2900X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurocritical Care",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025177900",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BRODSTONE FAMILY MEDICAL CENTER - SUPERIOR",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Superior, NE

Sources for this page

Verify at the official NPI Registry.