Provider Demographics
NPI:1417015058
Name:NORTHRUP INTERNAL MEDICINE AND PRIMARY CARE LLC
Entity Type:Organization
Organization Name:NORTHRUP INTERNAL MEDICINE AND PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-484-5656
Mailing Address - Street 1:4701 NORMAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5563
Mailing Address - Country:US
Mailing Address - Phone:402-484-5656
Mailing Address - Fax:402-484-5741
Practice Address - Street 1:4701 NORMAL BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5563
Practice Address - Country:US
Practice Address - Phone:402-484-5656
Practice Address - Fax:402-484-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NE099054Medicare ID - Type UnspecifiedMEDICARE NUMBER