1053396457 NPI number — MICHAEL L KOEBERNICK PA-C

Table of content: MICHAEL L KOEBERNICK PA-C (NPI 1053396457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053396457 NPI number — MICHAEL L KOEBERNICK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEBERNICK
Provider First Name:
MICHAEL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1053396457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 S 16TH STREET
Provider Second Line Business Mailing Address:
MEDICAL TOWER B, #305
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-488-3002
Provider Business Mailing Address Fax Number:
402-483-8787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 S 70TH ST
Provider Second Line Business Practice Location Address:
#400
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68510-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-488-3002
Provider Business Practice Location Address Fax Number:
402-483-8787
Provider Enumeration Date:
12/08/2005

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: 363AS0400X , with the licence number:  937 , 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: 47061995513 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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