=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114932860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAIRIE FIELDS FAMILY MEDICINE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 08/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W 23RD ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68025-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-721-7077
-----------------------------------------------------
Fax | 402-753-6056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 24737
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68124-0737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-502-8787
-----------------------------------------------------
Fax | 402-502-8788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SCOTT COONEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-721-7077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------