Provider Demographics
NPI:1568442572
Name:MIDWEST DERMATOLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:MIDWEST DERMATOLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTHERMUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-552-2568
Mailing Address - Street 1:4242 FARNAM ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2806
Mailing Address - Country:US
Mailing Address - Phone:402-552-2555
Mailing Address - Fax:402-552-2573
Practice Address - Street 1:4242 FARNAM ST
Practice Address - Street 2:SUITE 360
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2806
Practice Address - Country:US
Practice Address - Phone:402-552-2555
Practice Address - Fax:402-552-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECO3220OtherRAIL ROAD MEDICARE
NE2941OtherBLUE CROSS BLUE SHIELD
NE2941OtherBLUE CROSS BLUE SHIELD
NECO3220OtherRAIL ROAD MEDICARE
NE2941OtherBLUE CROSS BLUE SHIELD