Healthcare Provider Details

I. General information

NPI: 1417527243
Provider Name (Legal Business Name): MARK JOSEPH PICKERAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S 48TH ST
LINCOLN NE
68506-1283
US

IV. Provider business mailing address

1600 S 48TH ST
LINCOLN NE
68506-1283
US

V. Phone/Fax

Practice location:
  • Phone: 402-481-9049
  • Fax:
Mailing address:
  • Phone: 402-709-2654
  • Fax: 402-559-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9112
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: