Basic Information
| Provider Information | |||||||||
| NPI: | 1568412229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK GERSTBERGER DO LLC | ||||||||
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| OtherOrganizationName: | GERSTBERGER MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E GRANT AVE | ||||||||
| Address2: | |||||||||
| City: | ULYSSES | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678802515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203562432 | ||||||||
| FaxNumber: | 6203564050 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E GRANT AVE | ||||||||
| Address2: | |||||||||
| City: | ULYSSES | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678802515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203562432 | ||||||||
| FaxNumber: | 6203564050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | DYKSTRA | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6203562432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 05-26485 | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.