Healthcare Provider Details

I. General information

NPI: 1508389610
Provider Name (Legal Business Name): LINCOLN PEDIATRIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 S 62ND ST STE 100
LINCOLN NE
68516-3558
US

IV. Provider business mailing address

5625 S 62ND ST STE 100
LINCOLN NE
68516-3558
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-3834
  • Fax: 402-489-5049
Mailing address:
  • Phone: 402-489-3834
  • Fax: 402-489-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KATIE THOMPSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 402-489-3834