1255400206 NPI number — SUPERIOR STREET FAMILY PHYSICIANS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255400206 NPI number — SUPERIOR STREET FAMILY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR STREET FAMILY PHYSICIANS
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:
6
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:
1255400206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 FALLBROOK BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68521-9056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-441-3575
Provider Business Mailing Address Fax Number:
402-438-2107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 FALLBROOK BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68521-9056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-441-3575
Provider Business Practice Location Address Fax Number:
402-438-2107
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAATHOFF
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
MEMBER/PHYSICIAN
Authorized Official Telephone Number:
402-441-3575

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  19203 , 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)





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