NPIMap

Organization Active NPI

Grand Island Dermatology PC

  • Dermatology Physician
  • Grand Island, NE
National Provider Identifier
1609836535
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
22426 Issued in NE
Legal business name
GRAND ISLAND DERMATOLOGY PC
Practice address
418 N Webb Rd
Grand Island, NE 68803-4045
Phone
(308) 384-9300
Fax
(308) 384-4542
NPI assigned
Mar 24, 2006
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

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

Authorized official

Name
Patrick L SheridanNPI 1013363019
Title
Administrator
Phone
(308) 384-9300

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X 22426 NE
Dermatology Physician 207N00000X 22426 NE Primary

Addresses

Primary practice location

418 N Webb Rd
Grand Island, NE 68803-4045

Mailing address

PO Box 5436
Grand Island, NE 68802-5436
Phone (308) 384-9300

Other identifiers 2

IdentifierTypeStateIssuer
10025016800MedicaidNE
01726OtherNEBCBS OF NE

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050308000957 NE Part B Supplier - Clinic/Group Practice 0244284768 Receives reassigned benefits from 11 practitioners
Practice locations: Grand Island, NE

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
28D1017055Grand Island Dermatology PC418 N Webb Road, Grand Island, NE 68803Provider-performed microscopySep 15, 2027
28D2116830Grand Island Dermatology418 N Webb Road, Grand Island, NE 68803ComplianceDec 20, 2026

National Provider Directory

National Provider Directory

Locations

418 N Webb Rd
Grand Island, NE 68803
Phone (308) 382-1100

505 N Diers Ave
Grand Island, NE 68803
Phone (308) 384-9300

727 N Custer Ave
Grand Island, NE 68803
Phone (308) 384-7080

Practitioners & affiliated clinicians

Practitioners 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1143158400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1609836535",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5436",
            "city": "GRAND ISLAND",
            "state": "NE",
            "postal_code": "688025436",
            "telephone_number": "308-384-9300",
            "fax_number": "308-384-4542"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "418 N WEBB RD",
            "city": "GRAND ISLAND",
            "state": "NE",
            "postal_code": "688034045",
            "telephone_number": "308-384-9300",
            "fax_number": "308-384-4542"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND ISLAND DERMATOLOGY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-24",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "SHERIDAN",
        "authorized_official_first_name": "PATRICK",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "308-384-9300"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "NE",
            "license": "22426",
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NE",
            "license": "22426",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025016800",
            "state": "NE"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF NE",
            "identifier": "01726",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Island, NE

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 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.