NPIMap

Organization Active NPI

Pine Lake Health LLC

  • Family Medicine Physician
  • Lincoln, NE
National Provider Identifier
1417908666
Registry record updated Aug 30, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PINE LAKE HEALTH LLC
Practice address
2611 S 70TH St
Lincoln, NE 68506-2960
Phone
(402) 423-4200
Fax
(402) 423-4201
NPI assigned
May 12, 2006
Last updated
Aug 30, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 30, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Matthew M Glenn, MDNPI 1225080419
Title
President
Phone
(402) 423-4200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

2611 S 70TH St
Lincoln, NE 68506-2960

Mailing address

2611 S 70TH St
Lincoln, NE 68506-2960
Phone (402) 423-4200

Other identifiers 2

IdentifierTypeStateIssuer
02800OtherNEBCBS
10025371800MedicaidNE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060522000133 NE Part B Supplier - Clinic/Group Practice 1557372919 Receives reassigned benefits from 9 practitioners
2 other NPIs on this enrollment
Practice locations: Lincoln, NE; Waverly, NE

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
28D1054208Pine Lake Health, LLC2611 S 70TH Street, Lincoln, NE 68506Certificate of waiverJun 6, 2028

National Provider Directory

National Provider Directory

Locations

2611 S 70th St
Lincoln, NE 68506
Phone (402) 423-4200

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661817600000",
    "number": "1417908666",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2611 S 70TH ST",
            "city": "LINCOLN",
            "state": "NE",
            "postal_code": "685062960",
            "telephone_number": "402-423-4200",
            "fax_number": "402-423-4201"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2611 S 70TH ST",
            "city": "LINCOLN",
            "state": "NE",
            "postal_code": "685062960",
            "telephone_number": "402-423-4200",
            "fax_number": "402-423-4201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE LAKE HEALTH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-12",
        "last_updated": "2022-08-30",
        "certification_date": "2022-08-30",
        "status": "A",
        "authorized_official_last_name": "GLENN",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "402-423-4200",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "02800",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025371800",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lincoln, NE

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.