Healthcare Provider Details

I. General information

NPI: 1033316294
Provider Name (Legal Business Name): BRENT JONATHAN TIERNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST SUITE 300
OMAHA NE
68114-4108
US

IV. Provider business mailing address

PO BOX 10190
VIRGINIA BEACH VA
23450-0190
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5250
  • Fax: 402-354-3437
Mailing address:
  • Phone: 800-477-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5627
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number35.097164
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number27892
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: