NPIMap

Organization Active NPI

Jennie M Melham Memorial Medical Center Inc

  • Critical Access Hospital
  • Broken Bow, NE
National Provider Identifier
1982779641
Registry record updated Jul 31, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
100004 Issued in 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
Last updated
Jul 31, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
JENNIE M MELHAM MEMORIAL MEDICAL CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 31, 2023

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

Authorized official

Name
Kyle D Kellum
Title
Ceo and President
Phone
(308) 872-4100

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 100004 NE
Critical Access Hospital 282NC0060X 100004 NE Primary

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071129000462 NE Part A Provider - Critical Access Hospital 5799766440 Practice locations: Broken Bow, NE

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1982779641. Details of each certification follow.

Hospital certification: CCN 28Z365

Legal name
JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC
Doing business as
JENNIE M MELHAM MEMORIAL MEDICAL CENTER
Organization structure
CorporationNon-profit
Incorporated
Dec 27, 1955 in NE
Enrollment address
145 Memorial Dr
Broken Bow, NE 68822-1378
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Jennie M Melham Mem Med Ctr4 organizations share this tax ID, including this one
Part of
Jennie M Melham Mem Med Ctr

Other organizations with this tax ID 3

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

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
David a Minnick Individual Contracted Managing EmployeeChief of Staff Jan 1, 2023
Operational/Managerial ControlChief of Staff Jan 1, 2023
John Smith Individual Corporate Officer Jan 8, 2013
Corporate Director Jul 23, 2007
Joyce a Richardson Individual Corporate Officer Jan 8, 2013
Corporate Director Jan 11, 2011
Carla a Bazyn Individual Corporate OfficerCfo Dec 19, 2016
W-2 Managing EmployeeCfo Dec 19, 2016
Operational/Managerial ControlCfo Dec 19, 2016
Kyle D Kellum Individual Corporate OfficerPresident/Ceo Aug 14, 2023
W-2 Managing EmployeePresident/Ceo Aug 14, 2023
Operational/Managerial ControlPresident/Ceo Aug 14, 2023
Michael S Borders Individual Corporate Officer Jan 8, 2019
Corporate Director Jan 1, 2016
Corey a Staples Individual Corporate Officer Jan 1, 2023
Corporate Director Jan 8, 2019
Norval Books Individual Corporate Director Jan 10, 2023

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Affiliated clinicians 4

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1164067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690761600000",
    "number": "1982779641",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 250",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688220250",
            "telephone_number": "308-872-4100",
            "fax_number": "308-872-4175"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 MEMORIAL DR",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688221378",
            "telephone_number": "308-872-4100",
            "fax_number": "308-872-4175"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC",
        "enumeration_date": "2006-11-21",
        "last_updated": "2023-07-31",
        "certification_date": "2023-07-31",
        "status": "A",
        "authorized_official_last_name": "KELLUM",
        "authorized_official_first_name": "KYLE",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CEO AND PRESIDENT",
        "authorized_official_telephone_number": "308-872-4100"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "NE",
            "license": "100004",
            "primary": false
        },
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "NE",
            "license": "100004",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Broken Bow, NE

Sources for this page

Verify at the official NPI Registry.