Provider Demographics
NPI:1073708285
Name:KERRY A MCDONALD MD PC
Entity Type:Organization
Organization Name:KERRY A MCDONALD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROUCHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-330-0444
Mailing Address - Street 1:11704 W CENTER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4327
Mailing Address - Country:US
Mailing Address - Phone:402-334-3377
Mailing Address - Fax:402-691-9922
Practice Address - Street 1:11704 W CENTER RD STE 210
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4327
Practice Address - Country:US
Practice Address - Phone:402-334-3377
Practice Address - Fax:402-691-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025554600Medicaid
NEP0044497OtherTRAVELERS RR MEDICARE
H18791Medicare UPIN
NE10025554600Medicaid