Healthcare Provider Details

I. General information

NPI: 1578624433
Provider Name (Legal Business Name): INTERNAL MEDICINE CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S 19TH ST
BLAIR NE
68008-1907
US

IV. Provider business mailing address

407 S 19TH ST
BLAIR NE
68008-1907
US

V. Phone/Fax

Practice location:
  • Phone: 402-426-2210
  • Fax: 402-426-2235
Mailing address:
  • Phone: 402-426-2210
  • Fax: 402-426-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSIE M LEONARD
Title or Position: BILLING OFFICE
Credential: CMA
Phone: 402-426-2210