Provider Demographics
NPI:1477551794
Name:GARDNER & GARDNER, PA
Entity Type:Organization
Organization Name:GARDNER & GARDNER, PA
Other - Org Name:CAMA PRAIRIE FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MO
Authorized Official - Phone:208-983-3000
Mailing Address - Street 1:203 N A ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1201
Mailing Address - Country:US
Mailing Address - Phone:208-983-3000
Mailing Address - Fax:208-983-9276
Practice Address - Street 1:203 N A ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1201
Practice Address - Country:US
Practice Address - Phone:208-983-3000
Practice Address - Fax:208-983-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6671207Q00000X
IDM6670207Q00000X
IDNP416A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDG02767400Medicaid
IDG02767400Medicaid
F33101Medicare UPIN
S92921Medicare UPIN
ID1132574Medicare ID - Type Unspecified
ID1132565Medicare ID - Type Unspecified
ID1342429Medicare ID - Type Unspecified