Basic Information
Provider Information | |||||||||
NPI: | 1417068818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERWAY | ||||||||
FirstName: | RANDALL | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8055 O ST | ||||||||
Address2: | STE 300 | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685102580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024210896 | ||||||||
FaxNumber: | 4024210945 | ||||||||
Practice Location | |||||||||
Address1: | 555 S 70TH ST | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685102462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4022197142 | ||||||||
FaxNumber: | 4022198961 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 02/28/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20806 | NE | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 22910 | 01 | NE | MIDLAND'S CHOICE | OTHER | 0593509 | 05 | IA |   | MEDICAID | 39-86211 | 01 | NE | UHC | OTHER | 7719530 | 05 | SD |   | MEDICAID | 35184 | 01 | NE | BCBS | OTHER |