Basic Information
Provider Information | |||||||||
NPI: | 1033128251 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GANESAN | ||||||||
FirstName: | JAYANTHI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7261 MERCY RD | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681242311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023986255 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 16901 LAKESIDE HILLS CT | ||||||||
Address2: | ATTN: HOSPITAL MEDICINE | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681302318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023986255 | ||||||||
FaxNumber: | 4028298513 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 09/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22567 | NE | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | MD-37779 | IA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 22567 | NE | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 10025027500 | 05 | NE |   | MEDICAID |