1902355951 NPI number — BLOOMFIELD MEDICAL CLINIC

Table of content: (NPI 1902355951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902355951 NPI number — BLOOMFIELD MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMFIELD MEDICAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BLOOMFIELD MEDICAL CLINIC DBA OSMOND MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902355951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 S BROADWAY ST
Provider Second Line Business Mailing Address:
PO BOX 357
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68718-4419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-373-4341
Provider Business Mailing Address Fax Number:
402-373-4344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSMOND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68765-5722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-748-3366
Provider Business Practice Location Address Fax Number:
402-373-4344
Provider Enumeration Date:
09/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LAUCK
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-373-4341

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25844 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 1040 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2003 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 110153 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025588500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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