Basic Information
| Provider Information | |||||||||
| NPI: | 1316274665 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL J. GEHRKE M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 S WEBER ST STE B | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194480981 | ||||||||
| FaxNumber: | 7194480767 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 S WEBER ST STE B | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194480981 | ||||||||
| FaxNumber: | 7194480767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2009 | ||||||||
| LastUpdateDate: | 11/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | GEHRKE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7194480981 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 41056 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 37838334 | 05 | CO | MEDICAID |