1811067473 NPI number — BRYAN D BREDTHAUER MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811067473 NPI number — BRYAN D BREDTHAUER MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYAN D BREDTHAUER MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1811067473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11819 MIRACLE HILLS DR
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68154-5308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-492-9922
Provider Business Mailing Address Fax Number:
402-492-9944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11819 MIRACLE HILLS DR
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68154-5308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-492-9922
Provider Business Practice Location Address Fax Number:
402-492-9944
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREDTHAUER
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-492-9922

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  17324 , 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: 200023116 . This is a "RR MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 261369 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 00086 . This is a "BCBS NE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: DQ4240 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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