Provider Demographics
NPI:1932201803
Name:FAMILY AND SPORT MEDICINE, PC
Entity Type:Organization
Organization Name:FAMILY AND SPORT MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATZKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:308-537-7131
Mailing Address - Street 1:918 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1237
Mailing Address - Country:US
Mailing Address - Phone:308-537-7131
Mailing Address - Fax:308-537-7310
Practice Address - Street 1:918 20TH STREET
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-7131
Practice Address - Fax:308-537-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16542207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026082600Medicaid
NE10026082600Medicaid
NEE60084Medicare UPIN