Basic Information
| Provider Information | |||||||||
| NPI: | 1053799486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POPOVICH | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PUTMAN | ||||||||
| OtherFirstName: | JAMES | ||||||||
| OtherMiddleName: | KENNETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 POLE CREEK CROSSING | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691622900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545825 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 POLE CREEK XING STE 1 | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691622902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545554 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31424 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.