1235116963 NPI number — DR. MICHAEL JOSEPH MCGAHAN M.D.

Table of content: (NPI 1720307341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235116963 NPI number — DR. MICHAEL JOSEPH MCGAHAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGAHAN
Provider First Name:
MICHAEL
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1235116963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2717 LAKEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68801-7271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-381-6656
Provider Business Mailing Address Fax Number:
308-381-6680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 W FAIDLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-398-5560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2005

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: 207P00000X , with the licence number:  17445 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 047443 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 0424377 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1235116963 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47037877912 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235116963 . This is a "BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 20579960D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200579960B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03470 . This is a "NE BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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