Healthcare Provider Details

I. General information

NPI: 1922270354
Provider Name (Legal Business Name): PEDIATRIC AND MEDICAL GENETICS SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 A STREET SUITE 100
LINCOLN NE
68510-4283
US

IV. Provider business mailing address

7111 A STREET SUITE 100
LINCOLN NE
68510-4283
US

V. Phone/Fax

Practice location:
  • Phone: 402-484-5437
  • Fax: 402-484-5438
Mailing address:
  • Phone: 402-484-5437
  • Fax: 402-484-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number17436
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17436
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number17436
License Number StateNE

VIII. Authorized Official

Name: MRS. PAMELA J HEIDEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 402-484-5437