Provider Demographics
NPI:1831206739
Name:BYRD, PHYLLIS J (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:BYRD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 S 144TH ST STE 280
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5252
Mailing Address - Country:US
Mailing Address - Phone:402-778-5490
Mailing Address - Fax:402-614-1404
Practice Address - Street 1:2727 S 144TH ST STE 280
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5252
Practice Address - Country:US
Practice Address - Phone:402-778-5490
Practice Address - Fax:402-614-1404
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30664207Q00000X
NE19976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE80001102200Medicaid
NE10025310200Medicaid
NE10025310200Medicaid
IAI9125Medicare ID - Type Unspecified
IAG06732Medicare UPIN