Provider Demographics
NPI:1033316294
Name:TIERNEY, BRENT JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JONATHAN
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-5250
Practice Address - Fax:402-354-3437
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5627207V00000X
OH35.097164207VX0201X
NE27892207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100250445-00Medicaid
IA1033316294Medicaid
NE100264208-00Medicaid
NE100250445-00Medicaid