Basic Information
Provider Information | |||||||||
NPI: | 1386889442 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GIKK ORTHO SPECIALISTS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
Address2: | SUITE 200 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681302396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023998550 | ||||||||
FaxNumber: | 4023998455 | ||||||||
Practice Location | |||||||||
Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
Address2: | SUITE 200 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681302396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023998550 | ||||||||
FaxNumber: | 4023998455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2008 | ||||||||
LastUpdateDate: | 05/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FITZGIBBONS | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4023998550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GROSS, IWERSEN, KRATOCHVIL & KLEIN PC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 332B00000X |   | NE | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 10025800600 | 05 | NE |   | MEDICAID |