NPIMap

Organization Active NPI

Pine Lake Health LLC

Doing business as Waverly Health Care Urgent Care

  • Family Medicine Physician
  • Waverly, NE
National Provider Identifier
1780814475
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
Doing business as
Waverly Health Care Urgent Care
Practice address
13220 Callum Dr
Ste 4
Waverly, NE 68462-2561
Phone
(402) 786-5563
Fax
(402) 423-4201
NPI assigned
Jul 16, 2009
Last updated
Aug 30, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
PINE LAKE HEALTH, LLCAs reported in NPPES

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
Dr. Matthew M Glenn, MDNPI 1225080419
Title
Physician
Phone
(402) 423-4200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

13220 Callum Dr
Ste 4
Waverly, NE 68462-2561

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
10025748100MedicaidNE

Other names 1

  • Waverly Health Care Urgent Care Doing business as

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
This NPI is an additional NPI on the 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
28D1099228Waverly Health Care Urgent Care13220 Callum Drive Ste 4, Waverly, NE 68462Certificate of waiverJun 6, 2028

National Provider Directory

National Provider Directory
Part of
Pine Lake Health LLC

Locations

13220 Callum Dr
Ste 4
Waverly, NE 68462
Phone (402) 786-5563

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1247702400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661817600000",
    "number": "1780814475",
    "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": "13220 CALLUM DR",
            "address_2": "STE 4",
            "city": "WAVERLY",
            "state": "NE",
            "postal_code": "684622561",
            "telephone_number": "402-786-5563",
            "fax_number": "402-423-4201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE LAKE HEALTH LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PINE LAKE HEALTH, LLC",
        "enumeration_date": "2009-07-16",
        "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": "PHYSICIAN",
        "authorized_official_telephone_number": "402-423-4200",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "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": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025748100",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waverly Health Care Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Waverly Health Care Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waverly, 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.