Healthcare Provider Details

I. General information

NPI: 1669608147
Provider Name (Legal Business Name): PROFESSIONAL SERVICES OF CREIGHTON UNIVERSITY MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 30TH ST
OMAHA NE
68131-2137
US

IV. Provider business mailing address

601 N 30TH ST
OMAHA NE
68131-2137
US

V. Phone/Fax

Practice location:
  • Phone: 402-449-5371
  • Fax: 402-449-5020
Mailing address:
  • Phone: 402-449-5371
  • Fax: 402-449-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY ADAMS
Title or Position: SVP REGIONAL OPERATIONS, TENET
Credential:
Phone: 469-893-2563