MEDICARE: DR. GRANT E NITZEL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25573	NE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA1676019	OTHER	NE	MEDICARE PTAN

General Provider Information

NPI Number	:	1104821149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT E NITZEL M.D.

Provider Business Mailing Address
First Line	:	715 N SAINT JOSEPH AVE
Second Line	:
City	:	HASTINGS
State	:	NE
Zip	:	68901-4451
Country	:	US
Telephone Number	:	402-460-5836
Fax Number	:	402-460-5829

Provider Business Practice Location Address
First Line	:	223 E 14TH ST STE 100
Second Line	:
City	:	HASTINGS
State	:	NE
Zip	:	68901-3240
Country	:	US
Telephone Number	:	402-463-2929
Fax Number	:	402-463-2939

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/19/2019

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