Basic Information
| Provider Information | |||||||||
| NPI: | 1275587602 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN RADIOLOGY GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7239 | ||||||||
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| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9703422093 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 PINE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685165497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024816000 | ||||||||
| FaxNumber: | 4024234100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | WINJUM | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4024203512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | 2085N0700X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02908 | 01 | NE | BCBS | OTHER | 100324840A | 05 | KS | MEDICAID | 0520932 | 05 | IA | MEDICAID | C50295 | 01 | NE | RR MEDICARE | OTHER | 504033309 | 05 | MO | MEDICAID |