1528217395 NPI number — DR. JUSTIN GERHARD MADSON M.D., PHD

Table of content: DR. JUSTIN GERHARD MADSON M.D., PHD (NPI 1528217395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528217395 NPI number — DR. JUSTIN GERHARD MADSON M.D., PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADSON
Provider First Name:
JUSTIN
Provider Middle Name:
GERHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PHD
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:
1528217395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2014
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:
SUITE 360
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:
402-552-2555
Provider Business Mailing Address Fax Number:
402-552-2573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4242 FARNAM ST.
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68131-2850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-552-2555
Provider Business Practice Location Address Fax Number:
402-552-2598
Provider Enumeration Date:
09/16/2008

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: 207N00000X , with the licence number:  27129 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 26614 , 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: OK403917 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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