Provider Demographics
NPI:1194823302
Name:IMIG, CARMELLA N (MD)
Entity Type:Individual
Prefix:
First Name:CARMELLA
Middle Name:N
Last Name:IMIG
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 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 W GRUENTHER RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028
Practice Address - Country:US
Practice Address - Phone:402-332-2772
Practice Address - Fax:402-332-5446
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099189005Medicare PIN
NEG16931Medicare UPIN
NE274217Medicare ID - Type UnspecifiedINDIVIDUAL #
NE0101971OtherSHARE ADV - GRETNA
NEG16931Medicare UPIN