Basic Information
Provider Information | |||||||||
NPI: | 1841687191 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIANS CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | METHODIST PHYSICIANS CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3755 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681030755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023542100 | ||||||||
FaxNumber: | 4023542100 | ||||||||
Practice Location | |||||||||
Address1: | 11946 STANDING STONE DRIVE | ||||||||
Address2: |   | ||||||||
City: | GRETNA | ||||||||
State: | NE | ||||||||
PostalCode: | 680288094 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4028154500 | ||||||||
FaxNumber: | 4028154510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2015 | ||||||||
LastUpdateDate: | 10/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRAGES | ||||||||
AuthorizedOfficialFirstName: | TODD | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4023545609 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHYSICIANS CLINIC INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.