Healthcare Provider Details

I. General information

NPI: 1043482094
Provider Name (Legal Business Name): MIDWEST PAIN CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N 90TH ST
OMAHA NE
68114-2702
US

IV. Provider business mailing address

825 N 90TH ST
OMAHA NE
68114-2706
US

V. Phone/Fax

Practice location:
  • Phone: 402-391-7246
  • Fax: 402-408-1783
Mailing address:
  • Phone: 402-391-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MAUREEN E MAHONEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 402-391-7246