Healthcare Provider Details

I. General information

NPI: 1073024378
Provider Name (Legal Business Name): EDWARD ELLIS PEASE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 FARNAM ST
OMAHA NE
68132-3426
US

IV. Provider business mailing address

5608 FARNAM ST
OMAHA NE
68132-3426
US

V. Phone/Fax

Practice location:
  • Phone: 402-558-6817
  • Fax:
Mailing address:
  • Phone: 402-558-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number14096
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: