Healthcare Provider Details

I. General information

NPI: 1790349967
Provider Name (Legal Business Name): BRANDON GEBKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9515 HOLY CROSS LN
BREESE IL
62230-3618
US

IV. Provider business mailing address

303 SPRUCE ST
O FALLON IL
62269-1062
US

V. Phone/Fax

Practice location:
  • Phone: 618-526-4511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.019305
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: