1568773497 NPI number — PHYSICIANS CLINIC, INC.

Table of content: (NPI 1568773497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568773497 NPI number — PHYSICIANS CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568773497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8601 W DODGE RD STE 216
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68114-3495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-354-5451
Provider Business Mailing Address Fax Number:
402-354-5454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 RIDGE ST
Provider Second Line Business Practice Location Address:
STE. 311
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-396-4050
Provider Business Practice Location Address Fax Number:
712-328-1911
Provider Enumeration Date:
06/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GRAGES
Authorized Official First Name:
TODD
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-354-5609

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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