Provider Demographics
NPI:1245300565
Name:FANDERS, BARRY L (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:FANDERS
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 4460
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-0460
Mailing Address - Country:US
Mailing Address - Phone:866-491-5807
Mailing Address - Fax:
Practice Address - Street 1:6901 N 72ND ST
Practice Address - Street 2:ALEGENT IMMANUEL HOSPITAL DEPT OF RADIOLOGY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1709
Practice Address - Country:US
Practice Address - Phone:402-572-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE174192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0983783Medicaid
IA1245300565Medicaid
NENA1356016Medicare PIN
NEP00411711Medicare PIN
IA0983783Medicaid
NEE41151Medicare UPIN
NE399918813Medicare PIN
NE281536Medicare PIN
IA1245300565Medicaid
IAI20643Medicare PIN
NENA1355016Medicare PIN