Healthcare Provider Details

I. General information

NPI: 1568768935
Provider Name (Legal Business Name): MIDWEST REGIONAL EPILEPSY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 FARNAM ST STE 655
OMAHA NE
68131-2850
US

IV. Provider business mailing address

4242 FARNAM ST STE 655
OMAHA NE
68131-2850
US

V. Phone/Fax

Practice location:
  • Phone: 402-552-2270
  • Fax: 402-552-2276
Mailing address:
  • Phone: 402-552-2270
  • Fax: 402-552-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DEEPAK MADHAVAN
Title or Position: PRESIDENT
Credential: MD
Phone: 402-552-2270