Basic Information
| Provider Information | |||||||||
| NPI: | 1942408117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METHODIST PHYSICIANS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8601 W DODGE RD | ||||||||
| Address2: | SUITE # 216 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544822 | ||||||||
| FaxNumber: | 4023545454 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 SENATE AVE | ||||||||
| Address2: | SUITE # 105 | ||||||||
| City: | RED OAK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515661271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126237250 | ||||||||
| FaxNumber: | 7126237257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRAGES | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4023545601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0415257 | 05 | IA | MEDICAID | 42585 | 01 | IA | BCBS-IA | OTHER |