Fillmore County Medical Center P.C.
Organization Active NPI Family Medicine Physician · Geneva, NE
NPI 1740201771 · NPPES record last updated Jun 15, 2022
Key facts
- NPI
- 1740201771
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- FILLMORE COUNTY MEDICAL CENTER P.C.
- Practice address
- 1840 F St
Geneva, NE 68361-2211 - Phone
- (402) 759-4485
- Fax
- (402) 759-4487
- NPI assigned
- Jul 23, 2006
- Organization subpart
- No
Authorized official
- Name
- Jason L Bespalec, MD
- Title
- Owner
- Phone
- (402) 759-4485
Owners & managing parties with NPI records 1
Practitioners 15
-
Russell E Coash, PA-C
-
Michelle L Dorsey, PA-C
-
Brigett Effenbeck, PA-C
-
Natasha R Frei, PA
-
Grant A Anderson, PA-C
-
John R Jacobsen, MD
-
Abra Robbins, DO
-
Charles P Rogers, M.D.
-
Scott D Straka, MD
-
Jeffrey Wallman, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 28D0454775 | Fillmore County Medical Center PC | Provider-performed microscopy | Dec 21, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NE
Rural health clinic certification: CCN 283844
- Legal name
- FILLMORE COUNTY MEDICAL CENTER PC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Sep 23, 2003
- Last certification
- Nov 8, 2021
- Ownership / control type
- 1B
- Most recent change of ownership
- Nov 1, 2004 (1 total)
- Organization structure
- Corporation · Proprietary
- Incorporated
- Nov 1, 2004 in NE
- Enrollment address
- 1840 F Street
Geneva, NE 68361-2211
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Jason L Bespalec |
5% Or Greater Direct Ownership Interest |
Nov 1, 2004 | 100% |
| Corporate Officer |
Nov 1, 2004 | ||
| Corporate Director |
Nov 1, 2004 | ||
| W-2 Managing Employee |
Nov 1, 2004 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041111001003 | NE | Part B Supplier - Clinic/Group Practice | 4688638471 |
Receives reassigned benefits from 7 practitioners Practice locations: Geneva, NE |
| O20041220000202 | NE | Part a Provider - Rural Health Clinic | 4688638471 | Practice locations: Geneva, NE |
National Provider Directory
Locations
1840 F St
Geneva, NE 68361
Phone (402) 759-4485
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
1840 F St
Geneva, NE 68361-2211
Mailing address
1840 F St
Geneva, NE 68361-2211
Phone (402) 759-4485
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10025197500 | Medicaid | NE | |
| 10025178000 | Medicaid | NE |
Other providers in Geneva, NE
- Fillmore County Hospital
- Fillmore County Hospital
- Fillmore County Hospital
- Fillmore County Hospital
- Fillmore County Hospital
- Fillmore County School District 30-0025
- Marirose Fox
- Natasha R Frei
- Jolene Renee Frook
- Sue Ann Gelster
All providers in Geneva, NE · Family Medicine Physician in Nebraska
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 15, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.