1538193438 NPI number — MRS. ERINN L GARDNER MD

Table of content: MRS. ERINN L GARDNER MD (NPI 1538193438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538193438 NPI number — MRS. ERINN L GARDNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
ERINN
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TUCK
Provider Other First Name:
ERINN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538193438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8200 ROBERTS DR STE 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30350-4115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-952-8612
Provider Business Mailing Address Fax Number:
678-803-6944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 OLD BALL GROUND HWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-2890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-953-3331
Provider Business Practice Location Address Fax Number:
770-720-8211
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  59413 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 688142215B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 688142215D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 688142215E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 688142215C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 688142215F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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