Provider Demographics
NPI:1144277328
Name:GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC
Entity type:Organization
Organization Name:GROSS, IWERSEN, KRATOCHVIL & KLEIN MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FITZGIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-399-8550
Mailing Address - Street 1:17030 LAKESIDE HILLS PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2396
Mailing Address - Country:US
Mailing Address - Phone:402-399-8550
Mailing Address - Fax:402-399-8455
Practice Address - Street 1:7710 MERCY RD
Practice Address - Street 2:SUITE 224
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2372
Practice Address - Country:US
Practice Address - Phone:402-399-8550
Practice Address - Fax:402-399-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE332B00000X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02981OtherBCBS NE
NE10026130603Medicaid
NE10026130602Medicaid
NE=========13Medicaid
NE10026130603Medicaid
NE10026130602Medicaid
NE0238810002Medicare NSC