Basic Information
| Provider Information | |||||||||
| NPI: | 1386872372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUETZ | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYHAN | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | FRANCES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7261 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986255 | ||||||||
| FaxNumber: | 4028298513 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 MERCY RD | ||||||||
| Address2: | ATTN: HOSPITAL MEDICINE | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023985580 | ||||||||
| FaxNumber: | 4023985589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 26758 | NE | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 40425 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD-40425 | IA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 26758 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 098611083 | 01 | NE | MEDICARE PTAN | OTHER | I87040069 | 01 | IA | MEDICARE PTAN | OTHER |