1932130630 NPI number — DR. ELLIS BENJAMIN GARDNER MD FAAP

Table of content: DR. ELLIS BENJAMIN GARDNER MD FAAP (NPI 1932130630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932130630 NPI number — DR. ELLIS BENJAMIN GARDNER MD FAAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
ELLIS
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FAAP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932130630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 CALEB DYER LN
Provider Second Line Business Mailing Address:
MASCOMA COMMUNITY HEALTHCARE, INC.
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03748-3551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-673-5340
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 ROBERTS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANAAN
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03741-7644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-934-1464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

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: 208000000X , with the licence number:  037734 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 10330 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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