Basic Information
| Provider Information | |||||||||
| NPI: | 1669530630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTRICK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 8111 DODGE ST | ||||||||
| Address2: | STE. 263 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023548163 | ||||||||
| FaxNumber: | 4023542416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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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 | 2086X0206X | ME103180 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 207P00000X | ME103180 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2086X0206X | 25264 | NE | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1669530630 | 05 | IA | MEDICAID | 47068731707 | 05 | NE | MEDICAID | 10025868900 | 05 | NE | MEDICAID |