MEDICARE: BRYAN D BREDTHAUER MD PC

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	207X00000X	Orthopaedic Surgery Physician	17324	NE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200023116	OTHER	NE	RR MEDICARE
2	261369	OTHER	NE	MEDICARE GROUP PTAN
4	DQ4240	OTHER	NE	RR MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	00086	OTHER	NE	BCBS NE

General Provider Information

NPI Number	:	1811067473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRYAN D BREDTHAUER MD PC

Provider Business Mailing Address
First Line	:	11819 MIRACLE HILLS DR
Second Line	:	STE 203
City	:	OMAHA
State	:	NE
Zip	:	68154-5308
Country	:	US
Telephone Number	:	402-492-9922
Fax Number	:	402-492-9944

Provider Business Practice Location Address
First Line	:	11819 MIRACLE HILLS DR
Second Line	:	STE 203
City	:	OMAHA
State	:	NE
Zip	:	68154-5308
Country	:	US
Telephone Number	:	402-492-9922
Fax Number	:	402-492-9944

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRYAN D BREDTHAUER
Credential	:	M.D.
Telephone Number	:	402-492-9922

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	09/14/2010

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