Healthcare Provider Details

I. General information

NPI: 1457898116
Provider Name (Legal Business Name): MEDPEDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 N 195TH ST
ELKHORN NE
68022-5174
US

IV. Provider business mailing address

4209 N 195TH ST
ELKHORN NE
68022-5174
US

V. Phone/Fax

Practice location:
  • Phone: 402-557-5703
  • Fax:
Mailing address:
  • Phone: 402-557-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23344
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23344
License Number StateNE

VIII. Authorized Official

Name: DR. LORI BRUNNER-BUCK
Title or Position: OWNER
Credential: M.D.
Phone: 402-658-3014