MEDICARE: PHYSICIANS CLINIC, INC.

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1831258201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS CLINIC, INC.

Provider Business Mailing Address
First Line	:	8601 W DODGE RD
Second Line	:	SUITE # 216
City	:	OMAHA
State	:	NE
Zip	:	68114-3457
Country	:	US
Telephone Number	:	402-354-4822
Fax Number	:	402-354-5454

Provider Business Practice Location Address
First Line	:	10710 FORT ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-1230
Country	:	US
Telephone Number	:	402-354-7500
Fax Number	:	402-354-7505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TODD D. GRAGES
Credential	:
Telephone Number	:	402-354-5601

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	03/24/2010

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