Basic Information
| Provider Information | |||||||||
| NPI: | 1043526080 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREMONT HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FREMONT CARDIOVASCULAR SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 426 E 22ND STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027277796 | ||||||||
| FaxNumber: | 4027279574 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 EAST 22ND STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027277796 | ||||||||
| FaxNumber: | 4027279574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOOTH | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4027211610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FREMONT HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.