Provider Demographics
NPI:1003091497
Name:BLOOMFIELD MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:BLOOMFIELD MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
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 AVENUE
Mailing Address - Street 2:P O BOX 357
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NE
Mailing Address - Zip Code:68718-0357
Mailing Address - Country:US
Mailing Address - Phone:402-373-4341
Mailing Address - Fax:402-373-4344
Practice Address - Street 1:105 S BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NE
Practice Address - Zip Code:68718-0357
Practice Address - Country:US
Practice Address - Phone:402-373-4341
Practice Address - Fax:402-373-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1040363AM0700X
NE110153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025588500Medicaid
NEDO0210Medicare PIN
NEQ14026Medicare UPIN
NES27626Medicare UPIN
NE10025588500Medicaid