Basic Information
Provider Information | |||||||||
NPI: | 1356564991 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTLAND ORTHOPAEDIC AND SPORTS MEDICINE CLINIC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEARTLAND ORTHOPEDIC SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2740 N CLARKSON ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | NE | ||||||||
PostalCode: | 680257716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4027210090 | ||||||||
FaxNumber: | 4027219661 | ||||||||
Practice Location | |||||||||
Address1: | 2740 N CLARKSON SUITE 100 | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | NE | ||||||||
PostalCode: | 680257716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4027210090 | ||||||||
FaxNumber: | 4027219661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 08/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FISCHER | ||||||||
AuthorizedOfficialFirstName: | BRETT | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICAN/OWNER | ||||||||
AuthorizedOfficialTelephone: | 4027210090 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 15374 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.