Basic Information
Provider Information | |||||||||
NPI: | 1154621282 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MD WEST ONE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8005 FARNAM DR | ||||||||
Address2: | SUITE 305 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 68114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023989243 | ||||||||
FaxNumber: | 4023989253 | ||||||||
Practice Location | |||||||||
Address1: | 1 JACK FOSTER DRIVE | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | IA | ||||||||
PostalCode: | 51601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7122467240 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/22/2010 | ||||||||
LastUpdateDate: | 11/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HILL | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4023989243 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
No ID Information.