Basic Information
| Provider Information | |||||||||
| NPI: | 1699035931 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEGENT CREIGHTON CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALEGENT HEALTH CLINIC - CREIGHTON MEDICAL ASSOCIATES - RR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12809 W DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681542155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023434328 | ||||||||
| FaxNumber: | 4023434389 | ||||||||
| Practice Location | |||||||||
| Address1: | 12809 W DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681542155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023434328 | ||||||||
| FaxNumber: | 4023434389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAVANAUGH | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4023434328 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.