Provider Demographics
NPI:1457551889
Name:DERMATOLOGY SPECIALISTS OF OMAHA LLC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF OMAHA LLC
Other - Org Name:DERMATOLOGY SURGERY CENTER GROUP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OFFICE SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-763-1518
Mailing Address - Street 1:909 N 96TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2508
Mailing Address - Country:US
Mailing Address - Phone:402-330-4555
Mailing Address - Fax:402-330-4626
Practice Address - Street 1:909 N 96TH ST STE 201
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2508
Practice Address - Country:US
Practice Address - Phone:402-330-4555
Practice Address - Fax:402-330-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099992OtherMEDICARE GROUP
NE10025555000Medicaid