Provider Demographics
NPI:1710957311
Name:CHURCHILL, MELVIN ALBERT JR (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:ALBERT
Last Name:CHURCHILL
Suffix:JR
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 1:3901 PINE LAKE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5497
Mailing Address - Country:US
Mailing Address - Phone:402-420-1212
Mailing Address - Fax:402-328-0961
Practice Address - Street 1:3901 PINE LAKE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-420-1212
Practice Address - Fax:402-328-0961
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12536207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110047260/CO4240OtherRAILROAD MEDICARE PIN/GRP
00323/01942OtherBLUE SHIELD PIN/GROUP
00323/01942OtherBLUE SHIELD PIN/GROUP
B67781Medicare UPIN
NE47052796712Medicaid