Basic Information
| Provider Information | |||||||||
| NPI: | 1528025103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAECKLE | ||||||||
| FirstName: | C | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAECKLE | ||||||||
| OtherFirstName: | CHARLES | ||||||||
| OtherMiddleName: | THOMAS | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Practice Location | |||||||||
| Address1: | 4520 W 69TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059775000 | ||||||||
| FaxNumber: | 6059775377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1393 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 538R3GA | 01 | MN | MN BCBS - PLAN 538R2NO | OTHER | 6001092 | 05 | SD | MEDICAID | 4T613GA | 01 | MN | MN BCBS - PLAN 91057NO | OTHER | 931451029033 | 01 | MN | PREFERRED ONE | OTHER | 36112 | 01 | HEALTH PARTNERS | OTHER | 1122911 | 05 | IA | MEDICAID | 121283 | 01 | UCARE | OTHER | 0000970 | 01 | SD | SD BCBS | OTHER | 1393 | 01 | SD | DAKOTACARE | OTHER | 53989 | 01 | IA | IA BCBS | OTHER |