Provider Demographics
NPI:1053347187
Name:WEDGEWOOD LEGACY MEDICAL P.C.
Entity type:Organization
Organization Name:WEDGEWOOD LEGACY MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOSNAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-489-0334
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:STE S-109
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2564
Mailing Address - Country:US
Mailing Address - Phone:402-489-0334
Mailing Address - Fax:402-489-0733
Practice Address - Street 1:8055 O ST
Practice Address - Street 2:STE S-109
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2564
Practice Address - Country:US
Practice Address - Phone:402-489-8821
Practice Address - Fax:402-489-0733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025176100Medicaid
NE1902OtherBCBS
099567Medicare PIN
DC8274Medicare PIN