Jennie M Melham Memorial Medical Center Inc
Organization Active NPI Critical Access Hospital · Broken Bow, NE
NPI 1982779641 · NPPES record last updated Jul 31, 2023
Key facts
- NPI
- 1982779641
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Critical Access Hospital 282NC0060X
- License
- 100004 (NE)
- Legal business name
- JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
- Practice address
- 145 Memorial Dr
Broken Bow, NE 68822-1378 - Phone
- (308) 872-4100
- Fax
- (308) 872-4175
- NPI assigned
- Nov 21, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Authorized official
- Name
- Kyle D Kellum
- Title
- Ceo and President
- Phone
- (308) 872-4100
Owners & managing parties with NPI records 2
-
Norval Leon Books, M.D.
-
David A Minnick, MD
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 3
Related certifications (CCN) 1
Practitioners 8
-
John C Evans, CRNA
-
Timothy Bart Johnson, CRNA
-
Robert R Kahnk, MD
-
Jacob D Karmazin, PA-C
-
Brett R Lindau, DO
-
Julie A Lindstrom, D.O.
-
Paul Thrasher Denna, M.D.
-
David A Minnick, MD
Affiliated clinicians 4
-
Robert R Kahnk, MD
-
Brett R Lindau, DO
-
Julie A Lindstrom, D.O.
-
David A Minnick, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NE
Hospital certification: CCN 28Z365
- Legal name
- JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
- Doing business as
- JENNIE M MELHAM MEMORIAL MEDICAL CENTER
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 27, 1955 in NE
- Enrollment address
- 145 Memorial Dr
Broken Bow, NE 68822-1378
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| David a Minnick |
Contracted Managing Employee |
Jan 1, 2023 | |
| Operational/Managerial Control |
Jan 1, 2023 | ||
| John Smith |
Corporate Officer | Jan 8, 2013 | |
| Corporate Director | Jul 23, 2007 | ||
| Joyce a Richardson |
Corporate Officer | Jan 8, 2013 | |
| Corporate Director | Jan 11, 2011 | ||
| Carla a Bazyn |
Corporate Officer |
Dec 19, 2016 | |
| W-2 Managing Employee |
Dec 19, 2016 | ||
| Operational/Managerial Control |
Dec 19, 2016 | ||
| Kyle D Kellum |
Corporate Officer |
Aug 14, 2023 | |
| W-2 Managing Employee |
Aug 14, 2023 | ||
| Operational/Managerial Control |
Aug 14, 2023 | ||
| Michael S Borders |
Corporate Officer | Jan 8, 2019 | |
| Corporate Director | Jan 1, 2016 | ||
| Corey a Staples |
Corporate Officer | Jan 1, 2023 | |
| Corporate Director | Jan 8, 2019 | ||
| Norval Books |
Corporate Director | Jan 10, 2023 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071129000462 | NE | Part a Provider - Critical Access Hospital | 5799766440 | Practice locations: Broken Bow, NE |
National Provider Directory
- Tax ID family
- Jennie M Melham Mem Med Ctr
- Part of
- Jennie M Melham Mem Med Ctr
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medicare Defined Swing Bed Hospital Unit | 275N00000X | 100004 | NE | |
| Critical Access Hospital | 282NC0060X | 100004 | NE | Yes |
Addresses
Primary practice location
145 Memorial Dr
Broken Bow, NE 68822-1378
Mailing address
PO Box 250
Broken Bow, NE 68822-0250
Phone (308) 872-4100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0559 | Other | BLUE CROSS SWB NUMBER |
Other providers in Broken Bow, NE
- Jennie M Melham Memorial Medical Center
- Jennie M Melham Memorial Medical Center
- Jennie M Melham Memorial Medical Center
- Jennie M Melham Memorial Medical Center Inc
- Jennie M Melham Memorial Medical Center Inc
- Terry Jepsen
- Linda M Jezbera
- Tia Jilg
- Anna Maria Johnson
- Tamara Johnson
All providers in Broken Bow, NE · Critical Access Hospital in Nebraska
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 31, 2023. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.