Provider Demographics
NPI:1346566593
Name:STAR CITY MEDICAL CLINIC., PC
Entity Type:Organization
Organization Name:STAR CITY MEDICAL CLINIC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WASIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHUGHTAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-484-6080
Mailing Address - Street 1:1620 S 70TH ST
Mailing Address - Street 2:101
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1563
Mailing Address - Country:US
Mailing Address - Phone:402-484-6080
Mailing Address - Fax:
Practice Address - Street 1:1620 S 70TH ST
Practice Address - Street 2:101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1563
Practice Address - Country:US
Practice Address - Phone:402-484-6080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE270498Medicare PIN