Basic Information
| Provider Information | |||||||||
| NPI: | 1134153158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PHYSICIAN NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SALINE MEDICAL SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 Q ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024210896 | ||||||||
| FaxNumber: | 4024210945 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 E HIGHWAY 33 | ||||||||
| Address2: | |||||||||
| City: | CRETE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683332547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028263222 | ||||||||
| FaxNumber: | 4028263228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/31/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOOVER | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4024210896 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100252192 00 | 05 | NE | MEDICAID | 100249883 00 | 05 | NE | MEDICAID |