Provider Demographics
NPI:1457898116
Name:MEDPEDS PC
Entity Type:Organization
Organization Name:MEDPEDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNNER-BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-658-3014
Mailing Address - Street 1:4209 N 195TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5174
Mailing Address - Country:US
Mailing Address - Phone:402-557-5703
Mailing Address - Fax:
Practice Address - Street 1:4209 N 195TH ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-5174
Practice Address - Country:US
Practice Address - Phone:402-557-5703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23344207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty