Basic Information
| Provider Information | |||||||||
| NPI: | 1629160072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8401 W DODGE RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029556877 | ||||||||
| FaxNumber: | 4029556880 | ||||||||
| Practice Location | |||||||||
| Address1: | 9801 GILES ROAD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LA VISTA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029558400 | ||||||||
| FaxNumber: | 4029558401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/05/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 22435 | NE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10025373200 | 05 | NE | MEDICAID | 1157 | 01 | NE | BCBS | OTHER |