Provider Demographics
NPI:1851496947
Name:OMAHA CHILDRENS CINIC P.C.
Entity Type:Organization
Organization Name:OMAHA CHILDRENS CINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-330-5690
Mailing Address - Street 1:19102 Q STREET STE 102
Mailing Address - Street 2:OMAHA CHILDRENS CLINIC P.C.
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1558
Mailing Address - Country:US
Mailing Address - Phone:402-330-5690
Mailing Address - Fax:402-330-5689
Practice Address - Street 1:19102 Q STREET STE 102
Practice Address - Street 2:OMAHA CHILDRENS CLINIC P.C.
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-1558
Practice Address - Country:US
Practice Address - Phone:402-330-5690
Practice Address - Fax:402-330-5689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========12Medicaid