Healthcare Provider Details

I. General information

NPI: 1568948735
Provider Name (Legal Business Name): JMISKO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 HIDCOTE DR STE 103
LINCOLN NE
68516-5536
US

IV. Provider business mailing address

5800 HIDCOTE DR STE 103
LINCOLN NE
68516-5536
US

V. Phone/Fax

Practice location:
  • Phone: 402-484-5144
  • Fax: 402-484-5145
Mailing address:
  • Phone: 402-484-5144
  • Fax: 402-484-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNE

VIII. Authorized Official

Name: CHELE SMITH
Title or Position: ADMINISTRATOR
Credential:
Phone: 402-484-5144