1982653929 NPI number — DR. GLENN C GARDNER MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982653929 NPI number — DR. GLENN C GARDNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
GLENN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1982653929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7710 MERCY ROAD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-393-1338
Provider Business Mailing Address Fax Number:
402-393-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7710 MERCY ROAD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-393-1338
Provider Business Practice Location Address Fax Number:
402-393-6924
Provider Enumeration Date:
05/08/2006

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: 208600000X , with the licence number:  21949 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 91175912513 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com