Healthcare Provider Details

I. General information

NPI: 1932130630
Provider Name (Legal Business Name): ELLIS BENJAMIN GARDNER MD FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ROBERTS RD
CANAAN NH
03741-7644
US

IV. Provider business mailing address

43 CALEB DYER LN MASCOMA COMMUNITY HEALTHCARE, INC.
ENFIELD NH
03748-3551
US

V. Phone/Fax

Practice location:
  • Phone: 603-934-1464
  • Fax:
Mailing address:
  • Phone: 802-673-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10330
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10330
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number037734
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: