MEDICARE: OMAHA FACIAL PLASTIC SURGERY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2082S0099X	Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
2	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1922642412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMAHA FACIAL PLASTIC SURGERY PC

Provider Business Mailing Address
First Line	:	17838 BURKE ST STE 101
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2256
Country	:	US
Telephone Number	:	402-882-7722
Fax Number	:	402-739-8146

Provider Business Practice Location Address
First Line	:	17838 BURKE ST STE 101
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2256
Country	:	US
Telephone Number	:	402-882-7722
Fax Number	:	402-739-8146

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	ASHLEY HARBISON
Credential	:
Telephone Number	:	402-882-7722

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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