Provider Demographics
NPI:1629177530
Name:MEYER, MARK HERMAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HERMAN
Last Name:MEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5355 W 85TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-1422
Mailing Address - Country:US
Mailing Address - Phone:308-440-0748
Mailing Address - Fax:
Practice Address - Street 1:3015 AVENUE A
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-3525
Practice Address - Country:US
Practice Address - Phone:308-865-2565
Practice Address - Fax:308-865-2569
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14619C207X00000X
NE13732174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100202840AOtherKANSAS MEDICAID
NE07495OtherBCBS INDIVIDUAL PROVIDER
NE47-062901713Medicaid
KS100202840AOtherKANSAS MEDICAID
NE07495OtherBCBS INDIVIDUAL PROVIDER