Provider Demographics
NPI:1215984695
Name:MICEK, CONNIE S (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:MICEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:
Mailing Address - City:HARTINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68739-0937
Mailing Address - Country:US
Mailing Address - Phone:402-254-3935
Mailing Address - Fax:402-254-2393
Practice Address - Street 1:405 W DARLENE ST
Practice Address - Street 2:
Practice Address - City:HARTINGTON
Practice Address - State:NE
Practice Address - Zip Code:68739-4806
Practice Address - Country:US
Practice Address - Phone:402-254-3935
Practice Address - Fax:402-254-2393
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE274605Medicare ID - Type Unspecified
NEH47527Medicare UPIN