Basic Information
| Provider Information | |||||||||
| NPI: | 1497713291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14301 FNB PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681547200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024931212 | ||||||||
| FaxNumber: | 8889721672 | ||||||||
| Practice Location | |||||||||
| Address1: | 14301 FNB PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681547200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024931212 | ||||||||
| FaxNumber: | 8889721672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | FORBES | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 4024931212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 90622 | 01 | NE | WELLMARK BC/BS | OTHER | 10025173600 | 05 | NE | MEDICAID | 38457 | 01 | IA | WELLMARK BC/BS | OTHER |