Provider Demographics
NPI:1114962057
Name:SALYARDS, PHYLLIS (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:SALYARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N MINNESOTA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5256
Mailing Address - Country:US
Mailing Address - Phone:402-463-6781
Mailing Address - Fax:402-463-7056
Practice Address - Street 1:606 N MINNESOTA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5256
Practice Address - Country:US
Practice Address - Phone:402-463-6781
Practice Address - Fax:402-463-7056
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47055106500Medicaid
NE7394OtherBLUE CROSS BLUE SHIELD
NE93599SAMedicare ID - Type Unspecified
NEE11769Medicare UPIN