Provider Demographics
NPI:1457334369
Name:GARDNER, BETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:C
Last Name:GARDNER
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 1:525 JAMESTOWN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1751
Mailing Address - Country:US
Mailing Address - Phone:215-463-1483
Mailing Address - Fax:215-483-9185
Practice Address - Street 1:525 JAMESTOWN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1751
Practice Address - Country:US
Practice Address - Phone:215-463-1483
Practice Address - Fax:215-483-9185
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05624700207RG0100X
PAMD034274E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4540107Medicaid
PA001675813Medicaid
NJ672039TT5Medicare PIN
PA001675813Medicaid
NJ4540107Medicaid