Basic Information
| Provider Information | |||||||||
| NPI: | 1770854663 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALEGENT HEALTH BERGAN MERCY HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | ALEGENT HEALTH BERGAN MERCY MEDICAL CENTER PROFESSIONAL SERVICES | ||||||||
| 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: | 01/24/2012 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | KUIPER | ||||||||
| AuthorizedOfficialFirstName: | EVERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4023434420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LN0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.