Basic Information
| Provider Information | |||||||||
| NPI: | 1598788572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | SUSHIL | ||||||||
| MiddleName: | SOLOMON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 PINE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685163389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024898888 | ||||||||
| FaxNumber: | 4024211945 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 PINE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685163389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024898888 | ||||||||
| FaxNumber: | 4024211945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 12132 | NE | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 16674 | NC | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00763 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1900039 | 01 | UNITED HEALTH CARE | OTHER | 1253 | 01 | MIDLANDS CHOICE | OTHER | 340005458 | 01 | RR MEDICARE | OTHER |