Provider Demographics
NPI:1407930332
Name:GARDINER, STACEY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MARIE
Last Name:GARDINER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:LOOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF CARDIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6633
Mailing Address - Fax:414-805-6280
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF CARDIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6633
Practice Address - Fax:414-805-6280
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45885-020207R00000X
WI45886207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407930332Medicaid
WI680860652Medicare PIN
WI112373601Medicare PIN