Provider Demographics
NPI:1508032103
Name:GARDNER, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:GARDNER
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 1:222 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4436
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:
Practice Address - Street 1:222 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4436
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN522232085R0202X
ND129612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18613Medicaid
IAENROLLEDMedicaid
WIENROLLEDMedicaid
MNENROLLEDMedicaid
WIENROLLEDMedicaid
NDN719134Medicare PIN
MN300007097Medicare PIN