Basic Information
| Provider Information | |||||||||
| NPI: | 1932342706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | METHODIST PHYSICIANS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8601 W DODGE RD | ||||||||
| Address2: | SUITE #216 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023545451 | ||||||||
| FaxNumber: | 4023545454 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TABOR | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516532031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7125275204 | ||||||||
| FaxNumber: | 7125279346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAGES | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4023545609 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METHODIST HEALTH SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.