1548290471 NPI number — MARJORIE R SHREVE M.D.

Table of content: MARJORIE R SHREVE M.D. (NPI 1548290471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548290471 NPI number — MARJORIE R SHREVE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHREVE
Provider First Name:
MARJORIE
Provider Middle Name:
R
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:
1548290471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4242 FARNAM ST
Provider Second Line Business Mailing Address:
#150
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68131-2806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-552-6747
Provider Business Mailing Address Fax Number:
402-552-6741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 N 168TH CIR
Provider Second Line Business Practice Location Address:
#211
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68118-4091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-289-9325
Provider Business Practice Location Address Fax Number:
402-289-9829
Provider Enumeration Date:
07/04/2006

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: 207Q00000X , with the licence number:  21276 , 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: 10025310200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0596700 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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