Provider Demographics
NPI:1396711032
Name:GAGE, MATTHEW R (DC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:GAGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E. MADISON STE A
Mailing Address - Street 2:STE A
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-788-3713
Mailing Address - Fax:316-788-3231
Practice Address - Street 1:1701 E MADISON AVE
Practice Address - Street 2:STE A
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2079
Practice Address - Country:US
Practice Address - Phone:316-788-3713
Practice Address - Fax:316-788-3231
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS062064OtherBLUE CROSS BLUES SHIELD
KS062064Medicare ID - Type UnspecifiedPROVIDER ID#
KS062064OtherBLUE CROSS BLUES SHIELD
KSU99802Medicare UPIN