Provider Demographics
NPI:1386889442
Name:GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC
Entity type:Organization
Organization Name:GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FITZGIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-399-8550
Mailing Address - Street 1:17030 LAKESIDE HILLS PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2396
Mailing Address - Country:US
Mailing Address - Phone:402-399-8550
Mailing Address - Fax:402-399-8455
Practice Address - Street 1:17030 LAKESIDE HILLS PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2396
Practice Address - Country:US
Practice Address - Phone:402-399-8550
Practice Address - Fax:402-399-8455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROSS, IWERSEN, KRATOCHVIL & KLEIN PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
NE332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025800600Medicaid
NE0238810003Medicare NSC
NE10025800600Medicaid