Provider Demographics
NPI:1760561021
Name:GARDNER, SCOTT MICHAEL (MPT, OCS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 RACETRACK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3367
Mailing Address - Country:US
Mailing Address - Phone:410-641-8366
Mailing Address - Fax:410-641-8366
Practice Address - Street 1:11204 RACETRACK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OCEAN PINES
Practice Address - State:MD
Practice Address - Zip Code:21811-3367
Practice Address - Country:US
Practice Address - Phone:410-208-1525
Practice Address - Fax:410-208-1527
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD435138000Medicaid
MD435138000Medicaid