Provider Demographics
NPI:1790086999
Name:PARK STREET MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:PARK STREET MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUHLKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:402-993-2206
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:505 SOUTH PARK STREET
Mailing Address - City:GENOA
Mailing Address - State:NE
Mailing Address - Zip Code:68640
Mailing Address - Country:US
Mailing Address - Phone:402-993-2206
Mailing Address - Fax:402-993-2595
Practice Address - Street 1:505 SOUTH PARK STREET
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:NE
Practice Address - Zip Code:68640
Practice Address - Country:US
Practice Address - Phone:402-993-2206
Practice Address - Fax:402-993-2595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty