Provider Demographics
NPI:1134180664
Name:GAEKE, MARY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GAEKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:BROADSTONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:82 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3804
Mailing Address - Country:US
Mailing Address - Phone:513-422-3119
Mailing Address - Fax:513-420-1848
Practice Address - Street 1:82 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3804
Practice Address - Country:US
Practice Address - Phone:513-422-3119
Practice Address - Fax:513-420-1848
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-02
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044786207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH203767807OtherTAX ID
OH0428424Medicaid
OHA79464Medicare UPIN
OHGA0477884Medicare ID - Type UnspecifiedOHIO MEDICARE INDIVIDUAL