1114409984 NPI number — PREMIER ORTHOPAEDICS LLC

Table of content: DR. RENZO ANTONIO COSTA MD (NPI 1659017606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114409984 NPI number — PREMIER ORTHOPAEDICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ORTHOPAEDICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114409984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8560 FOXTAIL DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68526-6140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-219-3873
Provider Business Mailing Address Fax Number:
402-499-3245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8560 FOXTAIL DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68526-6140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-219-3873
Provider Business Practice Location Address Fax Number:
402-499-3245
Provider Enumeration Date:
08/29/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
402-219-3873

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10026748200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".