Basic Information
Provider Information | |||||||||
NPI: | 1295728368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREDERICKSON | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7500 MERCY RD | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681242319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8555244001 | ||||||||
FaxNumber: | 4023985589 | ||||||||
Practice Location | |||||||||
Address1: | 7500 MERCY RD | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681242319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023434328 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2005 | ||||||||
LastUpdateDate: | 09/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04-26524 | KS | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 108755 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 26061 | NE | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100293960B | 05 | KS |   | MEDICAID | 110199606 | 01 | MO | RR MCR | OTHER | P00652380 | 01 | KS | RR MCR | OTHER | 738529 | 01 |   | FIRST HEALTH | OTHER | 100293960D | 05 | KS |   | MEDICAID | 208471714 | 05 | MO |   | MEDICAID | 2292243 | 01 |   | AETNA | OTHER | 23432040 | 01 |   | BCBS | OTHER |