Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 0436174 | KS |
Y | 207QS0010X | Family Doctor - Sports Medicine | 16542 | NE |
NPI | 1154345973 |
---|---|
Provider Name | Dr. Gerald E Matzke JR. |
First Address | Gothenburg, NE 69138 |
Second Address | Gothenburg, NE 69138-1237 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2006 |
Last Update Date | 14/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
07025 | BC/BS (01) | NE |
10026082600 | (05) | NE |
E60084 | (02) | |
E60084 | (02) | NE |