Basic Information
| Provider Information | |||||||||
| NPI: | 1790861920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DE GRAAFF | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7261 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023985880 | ||||||||
| FaxNumber: | 4023986716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35616 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 22853 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200262110A | 01 | KS | MEDICAID | OTHER | 47070592313 | 05 | NE | MEDICAID | 05581066 | 01 | IA | MEDICAID | OTHER | I12883 | 01 | IA | MEDICARE | OTHER |