Provider Demographics
NPI:1427158690
Name:LONE TREE MEDICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:LONE TREE MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:MAHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-946-3845
Mailing Address - Street 1:2510 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68826-2123
Mailing Address - Country:US
Mailing Address - Phone:308-946-3845
Mailing Address - Fax:308-946-2357
Practice Address - Street 1:901 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:NE
Practice Address - Zip Code:68638-3151
Practice Address - Country:US
Practice Address - Phone:308-536-2458
Practice Address - Fax:308-536-2459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE TREE MEDICAL ASSOCIATES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 291U00000X, 332B00000X
NE261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD8193OtherRAILROAD MEDICARE
NE28D0886128OtherCMS CLIA IDENTIFICATION #
NE10025126000Medicaid
CD8193OtherRAILROAD MEDICARE
NE28D0886128OtherCMS CLIA IDENTIFICATION #
NE10025126000Medicaid
283848Medicare Oscar/Certification