Provider Demographics
NPI:1003011594
Name:GARDNER FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:GARDNER FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:978-630-3862
Mailing Address - Street 1:57 CITY HALL AVE
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2614
Mailing Address - Country:US
Mailing Address - Phone:978-630-3862
Mailing Address - Fax:978-630-4176
Practice Address - Street 1:57 CITY HALL AVE
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2614
Practice Address - Country:US
Practice Address - Phone:978-630-3862
Practice Address - Fax:978-630-4176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2141244207Q00000X
MA214124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty