Provider Demographics
NPI:1154312387
Name:GARDNER, MARY ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 CELEBRATION PL
Mailing Address - Street 2:STE 300
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5433
Mailing Address - Country:US
Mailing Address - Phone:321-939-3300
Mailing Address - Fax:321-939-3303
Practice Address - Street 1:410 CELEBRATION PL
Practice Address - Street 2:STE 300
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5433
Practice Address - Country:US
Practice Address - Phone:321-939-3300
Practice Address - Fax:321-939-3303
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 102236207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH8066149OtherCIGNA HEALTHCARE OF NH
NHP00160736OtherRAILROAD MEDICARE
ME417360099OtherMAINECARE
NH01Y007499NH01OtherANTHEM BCBS
NH4583146OtherAETNA
NH30204589Medicaid
NHRE7862Medicare ID - Type Unspecified
NH01Y007499NH01OtherANTHEM BCBS