Healthcare Provider Details

I. General information

NPI: 1609897248
Provider Name (Legal Business Name): MARK A BRISSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S 48TH ST NEONATOLGY
LINCOLN NE
68506-1283
US

IV. Provider business mailing address

2222 S 16TH ST STE 400A
LINCOLN NE
68502-3796
US

V. Phone/Fax

Practice location:
  • Phone: 402-481-7333
  • Fax: 402-481-7579
Mailing address:
  • Phone: 402-483-8590
  • Fax: 402-483-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10802
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number21523
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: