Provider Demographics
NPI:1780814475
Name:PINE LAKE HEALTH LLC
Entity type:Organization
Organization Name:PINE LAKE HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:M
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-423-4200
Mailing Address - Street 1:2611 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-2960
Mailing Address - Country:US
Mailing Address - Phone:402-423-4200
Mailing Address - Fax:402-423-4201
Practice Address - Street 1:13220 CALLUM DR
Practice Address - Street 2:STE 4
Practice Address - City:WAVERLY
Practice Address - State:NE
Practice Address - Zip Code:68462-2561
Practice Address - Country:US
Practice Address - Phone:402-786-5563
Practice Address - Fax:402-423-4201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE LAKE HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-16
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025748100Medicaid
NEDE6230Medicare PIN
099827Medicare PIN