Basic Information
| Provider Information | |||||||||
| NPI: | 1164423455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDINER | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.P | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AAUSER | ||||||||
| OtherFirstName: | MARY ANN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | C.R.N.P | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7580 BUCKINGHAM BLVD STE 220 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210763210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1509 RITCHIE HWY | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210122742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107577600 | ||||||||
| FaxNumber: | 4106268043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R085255 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9122236 | 01 | MD | AETNA PPO | OTHER | 687423-02 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 120106 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 7605-0053 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 400109500 | 05 | MD | MEDICAID | 500026827 | 01 | MD | RAILROAD MEDICARE | OTHER | 1978522 | 01 | MD | AETNA HMO | OTHER |