Basic Information
| Provider Information | |||||||||
| NPI: | 1891165601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GIKK ORTHO SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 E ELKHORN DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680256239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027210090 | ||||||||
| FaxNumber: | 4027219661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCARTHY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 4023998550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 10026130605 | 05 | NE | MEDICAID | 10026130604 | 05 | NE | MEDICAID |