MEDICARE: CHENEY RIDGE FAMILY MEDICAL CLINIC, PC

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	208D00000X	General Practice Physician	16656	NE

General Provider Information

NPI Number	:	1003044660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHENEY RIDGE FAMILY MEDICAL CLINIC, PC

Provider Business Mailing Address
First Line	:	3540 VILLAGE DR
Second Line	:	SUITE 100
City	:	LINCOLN
State	:	NE
Zip	:	68516-4706
Country	:	US
Telephone Number	:	402-420-7113
Fax Number	:

Provider Business Practice Location Address
First Line	:	3540 VILLAGE DR
Second Line	:	SUITE 100
City	:	LINCOLN
State	:	NE
Zip	:	68516-4706
Country	:	US
Telephone Number	:	402-420-7113
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICK J BERTOLINI
Credential	:
Telephone Number	:	402-420-7113

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	05/18/2020

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