Basic Information
| Provider Information | |||||||||
| NPI: | 1871653568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN RADIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7328 | ||||||||
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| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024899400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7121 STEPHANIE LN | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685165359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024203500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | WINJUM | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4024203500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10025493200 | 05 | NE | MEDICAID | 1871653568 | 05 | IA | MEDICAID |