Basic Information
| Provider Information | |||||||||
| NPI: | 1740933530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MD WEST ONE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8005 FARNAM DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023904111 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Practice Location | |||||||||
| Address1: | 20021 MANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680223233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023904111 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2022 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | FREDRICKS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | MAUREEN | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4023615260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.