Provider Demographics
NPI:1720030356
Name:MIDWEST EAR, NOSE & THROAT CLINIC, P.C.
Entity Type:Organization
Organization Name:MIDWEST EAR, NOSE & THROAT CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-778-5200
Mailing Address - Street 1:2727 S 144TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5225
Mailing Address - Country:US
Mailing Address - Phone:402-778-5200
Mailing Address - Fax:402-778-5216
Practice Address - Street 1:2727 S 144TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5225
Practice Address - Country:US
Practice Address - Phone:402-778-5200
Practice Address - Fax:402-778-5216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0983197Medicaid
IA0983197Medicaid