Provider Demographics
NPI:1982653929
Name:GARDNER, GLENN C (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7710 MERCY ROAD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124
Mailing Address - Country:US
Mailing Address - Phone:402-393-1338
Mailing Address - Fax:402-393-6924
Practice Address - Street 1:7710 MERCY ROAD
Practice Address - Street 2:SUITE 305
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124
Practice Address - Country:US
Practice Address - Phone:402-393-1338
Practice Address - Fax:402-393-6924
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21949208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE91175912513Medicaid
NE$$$$$$$$$Medicaid
NE91175912513Medicaid
NE275306Medicare PIN