Basic Information
| Provider Information | |||||||||
| NPI: | 1427056100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLONOSCOPY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9850 NICHOLAS STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023431122 | ||||||||
| FaxNumber: | 4023431177 | ||||||||
| Practice Location | |||||||||
| Address1: | 9850 NICHOLAS STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023431122 | ||||||||
| FaxNumber: | 4023431177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | STOCKTON | ||||||||
| AuthorizedOfficialFirstName: | ANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4023431122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASC038 | NE | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0570762 | 05 | IA | MEDICAID | 98448 | 01 | IA | BCBS OF IOWA | OTHER | P00106867 | 01 | RR MEDICARE PALMETO GPA | OTHER | D01791 | 01 | NE | BCBS OF NEBRASKA | OTHER | 10025038900 | 05 | NE | MEDICAID |