Healthcare Provider Details

I. General information

NPI: 1780117085
Provider Name (Legal Business Name): MADELINE BRUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE NOVOA

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 N 190TH PLZ STE 1100
ELKHORN NE
68022-3917
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-815-1700
  • Fax: 402-815-1959
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2021012619
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35631
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: