Provider Demographics
NPI:1225055783
Name:GARDINER, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GARDINER
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 1:75 REMITT DRIVE
Mailing Address - Street 2:LOCKBOX 1900
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1900
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:7245 RAIDER RD
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-3767
Practice Address - Country:US
Practice Address - Phone:636-916-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025344207P00000X
MOR6D18207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203338520Medicaid
MO203338520Medicaid
MO964805005Medicare PIN
MO203338520Medicaid
F28544Medicare UPIN
IL$$$$$$$$$-1Medicaid
MO011013209Medicare PIN
MO940353210Medicare PIN
MO940353211Medicare PIN
MO940354748Medicare PIN