Provider Demographics
NPI:1649254525
Name:CARDAMONE-RAYNER, MARK G
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:CARDAMONE-RAYNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-625-4031
Mailing Address - Fax:
Practice Address - Street 1:1015 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5294
Practice Address - Country:US
Practice Address - Phone:507-389-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43283207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI03409Medicare UPIN
MN040000716Medicare ID - Type Unspecified