Provider Demographics
NPI:1730299868
Name:SEVERSON, GREGORY C (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:C
Last Name:SEVERSON
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:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:17675 WELCH PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3551
Practice Address - Country:US
Practice Address - Phone:402-354-7600
Practice Address - Fax:402-354-7605
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13151208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0938571Medicaid
NE1002546400Medicaid
NE47068731785Medicaid
NE47068731796Medicaid
NE268420Medicare PIN