Provider Demographics
NPI:1174654321
Name:SOUTH LINCOLN MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTH LINCOLN MEDICAL GROUP
Other - Org Name:SOUTH LINCOLN MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-486-3444
Mailing Address - Street 1:1500 SO. 48TH ST.
Mailing Address - Street 2:SUITE 708
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506
Mailing Address - Country:US
Mailing Address - Phone:402-486-3444
Mailing Address - Fax:402-486-3590
Practice Address - Street 1:1500 S 48TH ST
Practice Address - Street 2:SUITE 708
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1225
Practice Address - Country:US
Practice Address - Phone:402-486-3444
Practice Address - Fax:402-486-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20387207Q00000X
NE14394207R00000X
NE18104207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEC53579Medicare UPIN
NEE09289Medicare UPIN
NEG69483Medicare UPIN