Provider Demographics
NPI:1053407064
Name:OMAHA NEPHROLOGY PC
Entity type:Organization
Organization Name:OMAHA NEPHROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOLDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-502-2747
Mailing Address - Street 1:1111 N 102ND CT STE 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2194
Mailing Address - Country:US
Mailing Address - Phone:402-502-2747
Mailing Address - Fax:402-502-2387
Practice Address - Street 1:1111 N 102ND CT STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2194
Practice Address - Country:US
Practice Address - Phone:402-502-2747
Practice Address - Fax:402-502-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECD3083OtherRAILROAD MEDICARE
IA0993865Medicaid
NE=========13Medicaid
NE=========OtherTRICARE NE GROUP
NE=========00Medicaid
NE=========13Medicaid
IA0993865Medicaid
NENA1910Medicare PIN