MEDICARE: OLYMPIA MEDICAL CLINIC

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	35034747	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891197786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIA MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3361 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127-1547
Country	:	US
Telephone Number	:	216-441-0660
Fax Number	:	216-441-0660

Provider Business Practice Location Address
First Line	:	3361 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127-1547
Country	:	US
Telephone Number	:	216-441-0660
Fax Number	:	216-441-0660

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. RUBEN T AGRA
Credential	:	M.D.
Telephone Number	:	216-441-0660

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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Directions to “OLYMPIA MEDICAL CLINIC ” Practice Location

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