Provider Demographics
NPI:1417012071
Name:ALLEN, ELISE C (MD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:C
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELISE
Other - Middle Name:C
Other - Last Name:JAECKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:555 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2136
Mailing Address - Country:US
Mailing Address - Phone:402-280-8100
Mailing Address - Fax:402-280-8103
Practice Address - Street 1:14040 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BOYS TOWN
Practice Address - State:NE
Practice Address - Zip Code:68010-7521
Practice Address - Country:US
Practice Address - Phone:402-778-6800
Practice Address - Fax:402-778-6874
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22545207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1000578Medicaid
NE1000483Medicaid
NE1000620Medicaid
NE242241OtherMIDLANDS CHOICE
IA2573105Medicaid
NE1000484Medicaid
IA4573105Medicaid
IA0573105Medicaid
NE1000572Medicaid
NE02751OtherBCBS BT
NE100251710-00Medicaid
IA3573105Medicaid
NE1000288Medicaid
IA1573105Medicaid
NE02756OtherBCBS ENT
NE1000479Medicaid
NE1000482Medicaid
IA4573105Medicaid
NE1000482Medicaid
NE100251710-00Medicaid