1124187984 NPI number — MS. MARY C DEK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124187984 NPI number — MS. MARY C DEK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DEK

Provider First Name:

MARY

Provider Middle Name:

C

Provider Name Prefix Text:

MS.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

MCGILL

Provider Other First Name:

MARY

Provider Other Middle Name:

C

Provider Other Name Prefix Text:

DR.

Provider Other Name Suffix Text:

Provider Other Credential Text:

M.D.

Provider Other Last Name Type Code:

1

NPI Number:

1124187984

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/11/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

16811 BURKE STREET

Provider Second Line Business Mailing Address:

STE 101

Provider Business Mailing Address City Name:

OMAHA

Provider Business Mailing Address State Name:

NE

Provider Business Mailing Address Postal Code:

68118

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

402-573-7337

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

18018 BURKE STREET

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ELKHORN

Provider Business Practice Location Address State Name:

NE

Provider Business Practice Location Address Postal Code:

68022-4417

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

402-573-7337

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

12/07/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  21119 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 21199 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1200591 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1200408 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1201454 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 24985 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
• Identifier: 34043 . This is a "BCBS OF NEBRASKA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
• Identifier: 1200590 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1200592 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 0538579 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1200405 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 1538579 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1201173 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".