MEDICARE: PARK STREET 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1790086999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK STREET MEDICAL CLINIC PC

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:	505 SOUTH PARK STREET
City	:	GENOA
State	:	NE
Zip	:	68640
Country	:	US
Telephone Number	:	402-993-2206
Fax Number	:	402-993-2595

Provider Business Practice Location Address
First Line	:	505 SOUTH PARK STREET
Second Line	:
City	:	GENOA
State	:	NE
Zip	:	68640
Country	:	US
Telephone Number	:	402-993-2206
Fax Number	:	402-993-2595

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BRIAN K. BUHLKE
Credential	:	D.O.
Telephone Number	:	402-993-2206

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/04/2010

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Directions to “PARK STREET MEDICAL CLINIC PC ” Practice Location

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