MEDICARE: BLOOMFIELD 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	363LF0000X	Family Nurse Practitioner	110153	NE
2	363AM0700X	Medical Physician Assistant	1040	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003091497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMFIELD MEDICAL CLINIC, PC

Provider Business Mailing Address
First Line	:	105 S BROADWAY AVENUE
Second Line	:	P O BOX 357
City	:	BLOOMFIELD
State	:	NE
Zip	:	68718-0357
Country	:	US
Telephone Number	:	402-373-4341
Fax Number	:	402-373-4344

Provider Business Practice Location Address
First Line	:	105 S BROADWAY AVENUE
Second Line	:
City	:	BLOOMFIELD
State	:	NE
Zip	:	68718-0357
Country	:	US
Telephone Number	:	402-373-4341
Fax Number	:	402-373-4344

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KEVIN D LAUCK
Credential	:	PA-C
Telephone Number	:	402-373-4341

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	03/29/2010

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