1336161470 NPI number — NICOLE M. LIEBENTRITT M.D.

Table of content: NICOLE M. LIEBENTRITT M.D. (NPI 1336161470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336161470 NPI number — NICOLE M. LIEBENTRITT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBENTRITT
Provider First Name:
NICOLE
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1336161470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10020 NICHOLAS STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68114-2188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-393-2023
Provider Business Mailing Address Fax Number:
402-393-3244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10020 NICHOLAS STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-393-2023
Provider Business Practice Location Address Fax Number:
402-393-3244
Provider Enumeration Date:
07/25/2006

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: 2084N0400X , with the licence number:  23233 , 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: 0592485 . This is a "MEDICAID INDIVIDUAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 30039 . This is a "BC/BS INDIVIDUAL" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 470542490 . This is a "TRICARE GROUP" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 01907 . This is a "BC/BS GROUP" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 247248 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 47054249013 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47054249012 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-00466 . This is a "SHARE ADVANTAGE LAKESIDE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 05-00454 . This is a "SHARE ADVANTAGE - BERGAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: P00239606 . This is a "RR MEDICARE INDIVIDUAL" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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