Provider Demographics
NPI:1497720155
Name:OMAHA ORTHOPEDIC CLINIC & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:OMAHA ORTHOPEDIC CLINIC & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-691-0500
Mailing Address - Street 1:11704 W CENTER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4375
Mailing Address - Country:US
Mailing Address - Phone:402-691-0500
Mailing Address - Fax:402-691-1586
Practice Address - Street 1:11704 W CENTER RD
Practice Address - Street 2:STE 200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4375
Practice Address - Country:US
Practice Address - Phone:402-691-0500
Practice Address - Fax:402-691-1586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECJ6643OtherRR MEDICARE GROUP
IAI16089OtherIA MEDICARE GROUP
IA09283Medicaid
IA09283Medicaid
IAI16089OtherIA MEDICARE GROUP