Provider Demographics
NPI:1427315654
Name:WAHOO FAMILY & SPORTS MEDICINE, P.C.
Entity type:Organization
Organization Name:WAHOO FAMILY & SPORTS MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-443-4600
Mailing Address - Street 1:567 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-1280
Mailing Address - Country:US
Mailing Address - Phone:402-443-4600
Mailing Address - Fax:402-443-4670
Practice Address - Street 1:567 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1280
Practice Address - Country:US
Practice Address - Phone:402-443-4600
Practice Address - Fax:402-443-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE179207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEG46140Medicare UPIN