Basic Information
| Provider Information | |||||||||
| NPI: | 1376518837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGETOWN MEDICAL, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GEORGETOWN MEDICAL, P.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3440 S 50TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681063829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025563000 | ||||||||
| FaxNumber: | 4029917115 | ||||||||
| Practice Location | |||||||||
| Address1: | 3440 S 50TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681063829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025563000 | ||||||||
| FaxNumber: | 4029917115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUTFLESS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | STANLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4025563000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | 218816123 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | 2801-1204 | 05 | NE | MEDICAID | 18358 | 01 | NE | STATE LIC.# G. HUTFLESS | OTHER | 1891765004 | 01 | NE | GEORGE HUTFLESS,MD NPI # | OTHER | 2801-18358 | 05 | NE | MEDICAID | 2965301 | 05 | IA | MEDICAID | BH1434050 | 01 | NE | DEA# GEORGE HUTFLESS MD | OTHER | 508741492 | 01 | NE | GEORGE HUTFLESS S.SEC. # | OTHER |