Provider Demographics
NPI:1629066154
Name:GAGE, JENNIFER CERNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CERNY
Last Name:GAGE
Suffix:
Gender:F
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:PO BOX 36351
Mailing Address - Street 2:SOUTHEAST ANESTHESIOLOGY CONSULTANTS PA
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6351
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:704-377-3389
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300390207L00000X
VT042.0014182207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00390OtherMEDICAID
NC8911269Medicaid
SCN00390OtherMEDICAID
G69410Medicare UPIN