MEDICARE: NORTHEAST NEBRASKA SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	490004329	OTHER	NE	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	F885	OTHER	NE	MIDLANDS CHOICE
3	01307	OTHER	NE	BCBS

General Provider Information

NPI Number	:	1861497380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST NEBRASKA SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	2701 W NORFOLK AVE
Second Line	:	STE 101
City	:	NORFOLK
State	:	NE
Zip	:	68701-4408
Country	:	US
Telephone Number	:	402-644-7262
Fax Number	:	402-644-7227

Provider Business Practice Location Address
First Line	:	2701 W NORFOLK AVE
Second Line	:	STE 101
City	:	NORFOLK
State	:	NE
Zip	:	68701-4408
Country	:	US
Telephone Number	:	402-644-7262
Fax Number	:	402-644-7227

Authorized Official
Title or Position	:	MEMBER OF BOARD OF MANAGERS
Name	:	KELLY A. DRISCOLL
Credential	:
Telephone Number	:	402-644-7637

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	02/24/2020

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