Basic Information
| Provider Information | |||||||||
| NPI: | 1609897248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRISSO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S 16TH ST | ||||||||
| Address2: | STE 400A | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024838590 | ||||||||
| FaxNumber: | 4024838599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S 48TH ST | ||||||||
| Address2: | NEONATOLGY | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685061283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024817333 | ||||||||
| FaxNumber: | 4024817579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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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 | 183500000X | 10802 | NE | N | Pharmacy Service Providers | Pharmacist | 2080N0001X | 21523 | NE | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200379810A | 05 | KS | MEDICAID | 470780857 02 | 05 | NE | MEDICAID |