Healthcare Provider Details

I. General information

NPI: 1740933530
Provider Name (Legal Business Name): MD WEST ONE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 01/31/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N 192ND STREET
ELKHORN NE
68022-5363
US

IV. Provider business mailing address

8005 FARNAM DR STE 305
OMAHA NE
68114-3426
US

V. Phone/Fax

Practice location:
  • Phone: 402-390-4111
  • Fax: 402-390-4115
Mailing address:
  • Phone: 402-390-4111
  • Fax: 402-399-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER MAUREEN FREDRICKS
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 402-361-5260