Provider Demographics
NPI:1295728368
Name:FREDERICKSON, THOMAS W (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:FREDERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2319
Mailing Address - Country:US
Mailing Address - Phone:855-524-4001
Mailing Address - Fax:402-398-5589
Practice Address - Street 1:7500 MERCY RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:402-343-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26524207R00000X
MO108755207R00000X
NE26061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100293960BMedicaid
MO110199606OtherRR MCR
KSP00652380OtherRR MCR
738529OtherFIRST HEALTH
KS100293960DMedicaid
MO208471714Medicaid
2292243OtherAETNA
23432040OtherBCBS
KS100293960BMedicaid