Provider Demographics
NPI:1003921834
Name:GACKE, JEROME THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:THOMAS
Last Name:GACKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68826-2123
Mailing Address - Country:US
Mailing Address - Phone:308-946-3845
Mailing Address - Fax:308-946-2357
Practice Address - Street 1:2510 18TH AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:NE
Practice Address - Zip Code:68826-2123
Practice Address - Country:US
Practice Address - Phone:308-946-3845
Practice Address - Fax:308-946-2357
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE30560OtherBLUECROSS BLUE SHIELD
NE5066OtherMIDLANDS CHOICE
NE5066OtherMIDLANDS CHOICE
NE266686Medicare ID - Type Unspecified