Provider Demographics
NPI:1609198480
Name:FREMONT NEUROLOGY LLC
Entity Type:Organization
Organization Name:FREMONT NEUROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:WINCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-727-9992
Mailing Address - Street 1:2735 N CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-7717
Mailing Address - Country:US
Mailing Address - Phone:402-727-9992
Mailing Address - Fax:402-727-7029
Practice Address - Street 1:2735 N CLARKSON ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-7717
Practice Address - Country:US
Practice Address - Phone:402-727-9992
Practice Address - Fax:402-727-7029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid