Provider Demographics
NPI:1184729451
Name:GARDNER, VERNON TRIP A (MD)
Entity type:Individual
Prefix:
First Name:VERNON TRIP
Middle Name:A
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:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:181 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4314
Practice Address - Country:US
Practice Address - Phone:207-992-2636
Practice Address - Fax:207-992-2638
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD156172084P0800X
ME0156172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME409660099Medicaid
G23743Medicare UPIN
ME0901Medicare PIN