Basic Information
| Provider Information | |||||||||
| NPI: | 1033162615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIMMELBERG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 N DIERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688034954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083981344 | ||||||||
| FaxNumber: | 3083981346 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 EAST 23RD STREET | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027211610 | ||||||||
| FaxNumber: | 4025599840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 22224 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10025333200 | 05 | NE | MEDICAID | BH8235485 | 01 | NE | DEA | OTHER |