Basic Information
| Provider Information | |||||||||
| NPI: | 1538141593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NILA MOORE NOVOTNY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COLUMBUS OTOLARYNGOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4508 38TH ST | ||||||||
| Address2: | STE 152 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025634500 | ||||||||
| FaxNumber: | 4025633520 | ||||||||
| Practice Location | |||||||||
| Address1: | 4508 38TH ST | ||||||||
| Address2: | SUITE #152 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025634500 | ||||||||
| FaxNumber: | 4025633520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOVOTNY | ||||||||
| AuthorizedOfficialFirstName: | NILA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 4025634500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 17352 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1538141593 | 01 | NE | TRIWEST | OTHER | 01923 | 01 | NE | BLUE CROSS GROUP # | OTHER | 10025979300 | 05 | NE | MEDICAID |