NPIMap

Antelope Memorial Hospital

Organization Active NPI Rural Health Clinic/Center · Tilden, NE

NPI 1386732709 · NPPES record last updated Nov 18, 2022

Key facts

NPI
1386732709
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
ANTELOPE MEMORIAL HOSPITAL
Practice address
200 S Antelope St
Tilden, NE 68781-4809
Phone
(402) 368-5520
NPI assigned
Oct 11, 2006
Organization subpart
Yes
Parent organization (as reported)
ANTELOPE MEMORIAL HOSPITAL

Authorized official

Name
Diane M Brugger
Title
Administrator
Phone
(402) 887-4151

Owners & managing parties with NPI records 1

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

  • Troy Olan Dawson, M.D. Family Medicine Physician · Neligh, NE · NPI 1831175256
    CMS ownership OPERATIONAL/MANAGERIAL CONTROL · W-2 MANAGING EMPLOYEE

Other NPIs with the same Medicare PAC ID 8

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

Corporate family (same tax ID) 9

Organizations that report the same tax identification number in the National Provider Directory.

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

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
28D0976261Amh - Tilden Clinic
200 S Antelope St, Tilden, NE 68781		Certificate of waiverMar 19, 2028

Medicare participation

Medicare fee-for-service enrollment
Enrolled in NE

Rural health clinic certification: CCN 283474

Legal name
ANTELOPE MEMORIAL HOSPITAL
Doing business as
AMH TILDEN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 1, 2004
Last certification
Apr 19, 2023
Ownership / control type
2B
Organization structure
Corporation · Non-profit
Incorporated
Mar 3, 1952 in NE
Enrollment address
200 S Antelope St
Tilden, NE 68781-4809
Related CCNs
281326

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Troy Olan Dawson
Individual 		W-2 Managing Employee
Medical Director		 Jul 1, 2004
Operational/Managerial Control
Medical Director		 Jul 1, 2004
Maury M Soper
Individual 		Corporate Director Mar 24, 2021
Gordon W Shrader
Individual 		Corporate Director May 1, 2009
David P Sullivan
Individual 		Corporate Director Jun 1, 1999
Tanya Sharp
Individual 		W-2 Managing Employee
Chief Clinical Operations Officer		 Oct 9, 2023
Operational/Managerial Control
Chief Clinical Operations Officer		 Oct 9, 2023
Jon Schilling
Individual 		Corporate Director Nov 24, 2015
Samantha Stoltz
Individual 		Corporate Director Jul 28, 2015
John J Mlnarik
Individual 		Corporate Officer Nov 1, 2009
Corporate Director Feb 1, 1985
Russell M Vetick
Individual 		Corporate Director Jul 24, 2018
Thomas J Zwingman
Individual 		Corporate Director Nov 28, 2018
Diane M Brugger
Individual 		Corporate Officer
Administrator		 Mar 1, 2019
W-2 Managing Employee
Administrator		 Mar 1, 2019
Operational/Managerial Control
Administrator		 Mar 1, 2019
Christopher W Twibell
Individual 		Corporate Director May 1, 2009
James E Meuret
Individual 		Corporate Officer Jul 29, 2020
Corporate Director Aug 1, 1995

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040709000626 NE Part a Provider - Rural Health Clinic 5496733156 Practice locations: Tilden, NE

National Provider Directory

Tax ID family
Antelope Memorial Hosp (10 organizations share this tax ID)
Part of
Antelope Memorial Hosp

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207Q00000X
Rural Health Clinic/Center 261QR1300X Yes

Addresses

Primary practice location

200 S Antelope St
Tilden, NE 68781-4809

Mailing address

PO Box 109
Neligh, NE 68756-0109
Phone (402) 887-5440

Other identifiers

IdentifierTypeStateIssuer
10025168600MedicaidNE

Other names

  • AMH Tilden Clinic Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Nov 18, 2022.

{
    "created_epoch": "1160524800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1668729600000",
    "number": "1386732709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 109",
            "city": "NELIGH",
            "state": "NE",
            "postal_code": "687560109",
            "telephone_number": "402-887-5440",
            "fax_number": "402-887-4564"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 S ANTELOPE ST",
            "city": "TILDEN",
            "state": "NE",
            "postal_code": "687814809",
            "telephone_number": "402-368-5520"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ANTELOPE MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ANTELOPE MEMORIAL HOSPITAL",
        "enumeration_date": "2006-10-11",
        "last_updated": "2022-11-18",
        "certification_date": "2022-11-18",
        "status": "A",
        "authorized_official_last_name": "BRUGGER",
        "authorized_official_first_name": "DIANE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "402-887-4151"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025168600",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AMH Tilden Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "AMH Tilden Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tilden, NE

All providers in Tilden, NE · Rural Health Clinic/Center in Nebraska

Sources for this page

Verify at the official NPI Registry.