Basic Information
| Provider Information | |||||||||
| NPI: | 1821440777 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHOEMAKER | ||||||||
| FirstName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
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| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 16120 W DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681182049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023540550 | ||||||||
| FaxNumber: | 4023540555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2016 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7830 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 31654 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1821440777 | 05 | IA | MEDICAID | 47068731727 | 05 | NE | MEDICAID |