Provider Demographics
NPI:1902355951
Name:BLOOMFIELD MEDICAL CLINIC
Entity Type:Organization
Organization Name:BLOOMFIELD MEDICAL CLINIC
Other - Org Name:BLOOMFIELD MEDICAL CLINIC DBA OSMOND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:402-373-4341
Mailing Address - Street 1:105 S BROADWAY ST
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NE
Mailing Address - Zip Code:68718-4419
Mailing Address - Country:US
Mailing Address - Phone:402-373-4341
Mailing Address - Fax:402-373-4344
Practice Address - Street 1:418 N STATE ST
Practice Address - Street 2:
Practice Address - City:OSMOND
Practice Address - State:NE
Practice Address - Zip Code:68765-5722
Practice Address - Country:US
Practice Address - Phone:402-748-3366
Practice Address - Fax:402-373-4344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOOMFIELD MEDICAL CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25844207Q00000X
NE1040363A00000X
NE2003363A00000X
NE110153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025588500Medicaid
NA1045004Medicare UPIN
NA1045005Medicare UPIN
NA1045002Medicare UPIN
NA1045001Medicare UPIN
NE10025588500Medicaid