Provider Demographics
NPI:1215281662
Name:NOT USED
Entity type:Organization
Organization Name:NOT USED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:Z
Authorized Official - Middle Name:
Authorized Official - Last Name:Z
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-865-2601
Mailing Address - Street 1:3219 CENTRAL AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-2949
Mailing Address - Country:US
Mailing Address - Phone:308-865-2601
Mailing Address - Fax:308-865-2829
Practice Address - Street 1:3219 CENTRAL AVE
Practice Address - Street 2:STE 106
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2949
Practice Address - Country:US
Practice Address - Phone:308-865-2601
Practice Address - Fax:308-865-2829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19175207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty