Healthcare Provider Details

I. General information

NPI: 1801076559
Provider Name (Legal Business Name): KAY E TICEN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6818 GROVER ST STE 201
OMAHA NE
68106-3632
US

IV. Provider business mailing address

6818 GROVER ST STE 201
OMAHA NE
68106-3632
US

V. Phone/Fax

Practice location:
  • Phone: 402-392-1278
  • Fax: 402-392-1291
Mailing address:
  • Phone: 402-392-1278
  • Fax: 402-392-1291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12608
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12608
License Number StateNE

VIII. Authorized Official

Name: JANET ANN DELP
Title or Position: BUSINESS MANAGER
Credential:
Phone: 402-392-1278