Basic Information
Provider Information | |||||||||
NPI: | 1811958416 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 575 S 70TH STREET | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685102471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024883322 | ||||||||
FaxNumber: | 4024881172 | ||||||||
Practice Location | |||||||||
Address1: | 575 S. 70TH STREET | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LINCOLN | ||||||||
State: | NE | ||||||||
PostalCode: | 685102471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024883322 | ||||||||
FaxNumber: | 4024881172 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 08/28/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 24527 | NE | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 101086076 | 05 | PA |   | MEDICAID | 470703099 | 01 | NE | UNITED HEALTHCARE | OTHER | 00902 | 01 | NE | BCBS | OTHER | 47070309913 | 05 | NE |   | MEDICAID |