Basic Information
| Provider Information | |||||||||
| NPI: | 1194789867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PATHOLOGY SPECIALISTS PLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008312402 | ||||||||
| FaxNumber: | 8435698503 | ||||||||
| Practice Location | |||||||||
| Address1: | 4955 F STREET | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027172875 | ||||||||
| FaxNumber: | 4027175231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | PENKA | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4027172875 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | CD8493 | 01 | RR MEDICARE | OTHER | 44191 | 01 | IA | BCBS | OTHER | 0508986 | 05 | IA | MEDICAID |