1609897248 NPI number — MARK A BRISSO MD

Table of content: MARK A BRISSO MD (NPI 1609897248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609897248 NPI number — MARK A BRISSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISSO
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1609897248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 S 16TH ST
Provider Second Line Business Mailing Address:
STE 400A
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68502-3796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-483-8590
Provider Business Mailing Address Fax Number:
402-483-8599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S 48TH ST
Provider Second Line Business Practice Location Address:
NEONATOLGY
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506-1283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-481-7333
Provider Business Practice Location Address Fax Number:
402-481-7579
Provider Enumeration Date:
07/21/2006

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: 183500000X , with the licence number:  10802 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 21523 , 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: 200379810A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 470780857 02 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".