Provider Demographics
NPI:1528151651
Name:BROKEN BOW CLINIC PC
Entity type:Organization
Organization Name:BROKEN BOW CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-872-6456
Mailing Address - Street 1:805 SOUTH F STREET
Mailing Address - Street 2:PO BOX 647
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-0647
Mailing Address - Country:US
Mailing Address - Phone:308-872-6456
Mailing Address - Fax:308-872-6040
Practice Address - Street 1:805 SOUTH F STREET
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-0647
Practice Address - Country:US
Practice Address - Phone:308-872-6456
Practice Address - Fax:308-872-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1008510001Medicare NSC