Basic Information
| Provider Information | |||||||||
| NPI: | 1336125202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEBRASKA HEART INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82585 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685012585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283989 | ||||||||
| Practice Location | |||||||||
| Address1: | 7440 SOUTH 91ST STREET | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | AUSDEMORE | ||||||||
| AuthorizedOfficialFirstName: | MARLIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4023283721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 20 862808 01 | 05 | KS | MEDICAID | 0537043 | 05 | IA | MEDICAID |