Basic Information
Provider Information | |||||||||
NPI: | 1194717413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLSON | ||||||||
FirstName: | RAYMOND | ||||||||
MiddleName: | LIONEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1167 | ||||||||
Address2: |   | ||||||||
City: | NORTH PLATTE | ||||||||
State: | NE | ||||||||
PostalCode: | 691031167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3085688000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 611 W FRANCIS ST STE 160 | ||||||||
Address2: |   | ||||||||
City: | NORTH PLATTE | ||||||||
State: | NE | ||||||||
PostalCode: | 691010614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3085683500 | ||||||||
FaxNumber: | 3085683738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2005 | ||||||||
LastUpdateDate: | 08/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 224 | NE | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 224 | NE | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 47080978500 | 05 | NE |   | MEDICAID | 10025770900 | 05 | NE |   | MEDICAID |