Healthcare Provider Details

I. General information

NPI: 1942408117
Provider Name (Legal Business Name): PHYSICIANS CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SENATE AVE SUITE # 105
RED OAK IA
51566-1271
US

IV. Provider business mailing address

8601 W DODGE RD SUITE # 216
OMAHA NE
68114-3457
US

V. Phone/Fax

Practice location:
  • Phone: 712-623-7250
  • Fax: 712-623-7257
Mailing address:
  • Phone: 402-354-4822
  • Fax: 402-354-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD D. GRAGES
Title or Position: PRESIDENT
Credential:
Phone: 402-354-5601