Provider Demographics
NPI:1720162993
Name:WESTERN NEBRASKA UROLOGY LLC
Entity Type:Organization
Organization Name:WESTERN NEBRASKA UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ACINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PACS
Authorized Official - Phone:308-630-2450
Mailing Address - Street 1:2 WEST 42ND STREET
Mailing Address - Street 2:SUITE 3600
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361
Mailing Address - Country:US
Mailing Address - Phone:308-630-2450
Mailing Address - Fax:308-630-2492
Practice Address - Street 1:2 WEST 42ND STREET
Practice Address - Street 2:SUITE 3600
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361
Practice Address - Country:US
Practice Address - Phone:308-630-2450
Practice Address - Fax:308-630-2492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22723208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
241716OtherMIDLANDS CHOICE
DD6108OtherRR MCARE
NE07283OtherBLUE CROSS
NE10025264700Medicaid
DD6108OtherRR MCARE
NE07283OtherBLUE CROSS