Provider Demographics
NPI:1609836535
Name:GRAND ISLAND DERMATOLOGY PC
Entity type:Organization
Organization Name:GRAND ISLAND DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-384-9300
Mailing Address - Street 1:PO BOX 5436
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5436
Mailing Address - Country:US
Mailing Address - Phone:308-384-9300
Mailing Address - Fax:308-384-4542
Practice Address - Street 1:418 N WEBB RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4045
Practice Address - Country:US
Practice Address - Phone:308-384-9300
Practice Address - Fax:308-384-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22426174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01726OtherBCBS OF NE
NE10025016800Medicaid
NE10025016800Medicaid