1285792903 NPI number — MARY L DREY MD

Table of content: MARY L DREY MD (NPI 1285792903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285792903 NPI number — MARY L DREY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREY
Provider First Name:
MARY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAISSON
Provider Other First Name:
MARY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285792903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4701 NORMAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506-5563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-488-5050
Provider Business Mailing Address Fax Number:
402-488-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4701 NORMAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506-5563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-488-5050
Provider Business Practice Location Address Fax Number:
402-488-5001
Provider Enumeration Date:
12/05/2006

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: 207R00000X , with the licence number:  19670 , 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: 100263068-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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