Healthcare Provider Details

I. General information

NPI: 1992881189
Provider Name (Legal Business Name): THOMAS GARLAND MAGRUDER IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8720 FREDERICK ST STE 100
OMAHA NE
68124-3076
US

IV. Provider business mailing address

8720 FREDERICK ST STE 100
OMAHA NE
68124-3076
US

V. Phone/Fax

Practice location:
  • Phone: 402-397-0700
  • Fax: 402-397-1807
Mailing address:
  • Phone: 402-397-0700
  • Fax: 402-397-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16747
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: