Healthcare Provider Details

I. General information

NPI: 1003921834
Provider Name (Legal Business Name): JEROME THOMAS GACKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 18TH AVE
CENTRAL CITY NE
68826-2123
US

IV. Provider business mailing address

2510 18TH AVE
CENTRAL CITY NE
68826-2123
US

V. Phone/Fax

Practice location:
  • Phone: 308-946-3845
  • Fax: 308-946-2357
Mailing address:
  • Phone: 308-946-3845
  • Fax: 308-946-2357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15361
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: