Provider Demographics
NPI:1669608147
Name:PROFESSIONAL SERVICES OF CREIGHTON UNIVERSITY MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:PROFESSIONAL SERVICES OF CREIGHTON UNIVERSITY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP REGIONAL OPERATIONS, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2563
Mailing Address - Street 1:601 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2137
Mailing Address - Country:US
Mailing Address - Phone:402-449-5371
Mailing Address - Fax:402-449-5020
Practice Address - Street 1:601 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2137
Practice Address - Country:US
Practice Address - Phone:402-449-5371
Practice Address - Fax:402-449-5020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA1475Medicare PIN