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	207Y00000X	Otolaryngology Physician
2	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician

General Provider Information

NPI Number	:	1992246656
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	:
Fax Number	:

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	:	402-758-5330
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN M HARBISON
Credential	:	MD
Telephone Number	:	816-665-7768

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	01/13/2021

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