Basic Information
Provider Information | |||||||||
NPI: | 1407946650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST NEBRASKA SURGERY P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 128 | ||||||||
Address2: | 1110 JACKSON ST | ||||||||
City: | BEATRICE | ||||||||
State: | NE | ||||||||
PostalCode: | 683100128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4022284236 | ||||||||
FaxNumber: | 4022284668 | ||||||||
Practice Location | |||||||||
Address1: | 1110 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | BEATRICE | ||||||||
State: | NE | ||||||||
PostalCode: | 683102117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4022284236 | ||||||||
FaxNumber: | 4022284668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUTLER | ||||||||
AuthorizedOfficialFirstName: | BLAKE | ||||||||
AuthorizedOfficialMiddleName: | ALAN | ||||||||
AuthorizedOfficialTitleorPosition: | SURGEON | ||||||||
AuthorizedOfficialTelephone: | 4022284236 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.