Provider Demographics
NPI:1205835469
Name:GARTNER, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:GARTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MAYO CLINIC HEALTH SYSTEM
Mailing Address - Street 2:1025 MARSH ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-625-4031
Mailing Address - Fax:
Practice Address - Street 1:MAYO CLINIC HEALTH SYSTEM
Practice Address - Street 2:1025
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5600
Practice Address - Country:US
Practice Address - Phone:507-624-4031
Practice Address - Fax:507-624-4031
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI051637207P00000X
MI4301051637207Q00000X
KS432455207Q00000X
MN56163207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MG051637OtherBLUE CROSS BLUE SHIELD
MI3446678Medicaid
KSP00605126Medicare PIN
MIE71072Medicare UPIN
KS200542820AMedicare PIN
MG051637OtherBLUE CROSS BLUE SHIELD