Provider Demographics
NPI:1780874826
Name:NEBRASKA MEDICAL AESTHETICS, LLC
Entity type:Organization
Organization Name:NEBRASKA MEDICAL AESTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-397-2300
Mailing Address - Street 1:9802 NICHOLAS ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2106
Mailing Address - Country:US
Mailing Address - Phone:402-397-2300
Mailing Address - Fax:402-397-2303
Practice Address - Street 1:9802 NICHOLAS ST
Practice Address - Street 2:SUITE 305
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2106
Practice Address - Country:US
Practice Address - Phone:402-397-2300
Practice Address - Fax:402-397-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025539700Medicaid
NE00196OtherBCBS
NE00196OtherBCBS
5950000001Medicare NSC