Healthcare Provider Details

I. General information

NPI: 1932427069
Provider Name (Legal Business Name): ROSS EDWARD MATHIASEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981150 NEBRASKA MEDICAL CTR
OMAHA NE
68198-1150
US

IV. Provider business mailing address

981150 NEBRASKA MEDICAL CTR
OMAHA NE
68198-1150
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-6637
  • Fax: 402-559-9659
Mailing address:
  • Phone: 402-559-6637
  • Fax: 402-559-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR-8823
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number40647
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number28791
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: