Basic Information
| Provider Information | |||||||||
| NPI: | 1225322910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEBRASKA SPECIALTY NETWORK, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEBRASKA HEART INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 Q ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023284572 | ||||||||
| FaxNumber: | 4024210946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 Q ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023284572 | ||||||||
| FaxNumber: | 4024210946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYNE-ULRICH | ||||||||
| AuthorizedOfficialFirstName: | MARCI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4023284572 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 10026072200 | 05 | NE | MEDICAID | 10026072600 | 05 | NE | MEDICAID | 10026072400 | 05 | NE | MEDICAID | 10026380000 | 05 | NE | MEDICAID | 10026072000 | 05 | NE | MEDICAID | 10026072300 | 05 | NE | MEDICAID | 10026072700 | 05 | NE | MEDICAID | 10026283500 | 05 | NE | MEDICAID | 10026072500 | 05 | NE | MEDICAID |