1538151204 NPI number — MR. BRETT VAN KETTELHUT M.D.

Table of content: MR. BRETT VAN KETTELHUT M.D. (NPI 1538151204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538151204 NPI number — MR. BRETT VAN KETTELHUT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTELHUT
Provider First Name:
BRETT
Provider Middle Name:
VAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538151204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2808 S 80 AVE
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68124-3253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-391-1800
Provider Business Mailing Address Fax Number:
402-391-1563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2808 S 80 AVE
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68124-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-391-1800
Provider Business Practice Location Address Fax Number:
402-391-1563
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KI0005X , with the licence number:  21408 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 21408 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47060801504 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47060801514 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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