MEDICARE: THOMAS W FREDERICKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	04-26524	KS
2	207R00000X	Internal Medicine Physician	108755	MO
3	207R00000X	Internal Medicine Physician	26061	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	110199606	OTHER	MO	RR MCR
3	P00652380	OTHER	KS	RR MCR
4	738529	OTHER		FIRST HEALTH
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	2292243	OTHER		AETNA
8	23432040	OTHER		BCBS

General Provider Information

NPI Number	:	1295728368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS W FREDERICKSON M.D.

Provider Business Mailing Address
First Line	:	7500 MERCY RD
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68124-2319
Country	:	US
Telephone Number	:	855-524-4001
Fax Number	:	402-398-5589

Provider Business Practice Location Address
First Line	:	7500 MERCY RD
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68124-2319
Country	:	US
Telephone Number	:	402-343-4328
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	09/29/2016

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Directions to “ THOMAS W FREDERICKSON M.D.” Practice Location

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