Basic Information
| Provider Information | |||||||||
| NPI: | 1144277328 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC | ||||||||
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| OtherOrganizationName: | GIKK ORTHO SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Practice Location | |||||||||
| Address1: | 7710 MERCY RD | ||||||||
| Address2: | SUITE 224 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | FITZGIBBONS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4023998550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NE | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02981 | 01 | NE | BCBS NE | OTHER | 10026130603 | 05 | NE | MEDICAID | 10026130602 | 05 | NE | MEDICAID |