Basic Information
Provider Information | |||||||||
NPI: | 1396704854 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'NEIL | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2725 S 144TH ST STE 212 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681445253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4026370800 | ||||||||
FaxNumber: | 4026370808 | ||||||||
Practice Location | |||||||||
Address1: | 2725 S 144TH ST | ||||||||
Address2: | #110 | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681445243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4026370400 | ||||||||
FaxNumber: | 4026370401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2006 | ||||||||
LastUpdateDate: | 12/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 20601 | IA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 11052 | NE | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0900228 | 01 | NE | AMERICHOICE-2725 S 144 | OTHER | 0915686 | 05 | IA |   | MEDICAID | 200046306 | 01 | IA | RAILROAD MEDICARE | OTHER | 3531707 | 05 | IA |   | MEDICAID | 200011553 | 01 | NE | RAILROAD MEDICARE | OTHER | 33565 | 01 | IA | WELLMARK-CLARINDA | OTHER |