Healthcare Provider Details

I. General information

NPI: 1184759029
Provider Name (Legal Business Name): SIDNEY M LONGWELL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981150 NEBRASKA MEDICAL CTR
OMAHA NE
68198-1150
US

IV. Provider business mailing address

14922 OGDEN ST
OMAHA NE
68116-4529
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-6705
  • Fax:
Mailing address:
  • Phone: 402-991-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23313
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.025714
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: