1639256795 NPI number — MRS. KELLY MADIGAN ERLANDSON LADC 239

Table of content: MRS. KELLY MADIGAN ERLANDSON LADC 239 (NPI 1639256795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639256795 NPI number — MRS. KELLY MADIGAN ERLANDSON LADC 239

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERLANDSON
Provider First Name:
KELLY
Provider Middle Name:
MADIGAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LADC 239
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:
1639256795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 LAKE ST
Provider Second Line Business Mailing Address:
BRYAN LGH INDEPENDENCE CENTER
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:
402-481-5893
Provider Business Mailing Address Fax Number:
402-481-5495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 LAKE ST
Provider Second Line Business Practice Location Address:
BRYAN LGH INDEPENDENCE CENTER
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-481-5893
Provider Business Practice Location Address Fax Number:
402-481-5495
Provider Enumeration Date:
11/01/2006

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: 101YA0400X , 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: 47057655277 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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