=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407901812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH R GAARDER MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4221 OAKRIDGE LANE
-----------------------------------------------------
City | CHEVY CHASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-6058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-656-0554
-----------------------------------------------------
Fax | 301-656-0554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4221 OAKRIDGE LANE
-----------------------------------------------------
City | CHEVY CHASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-6058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-656-0554
-----------------------------------------------------
Fax | 301-656-0554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KENNETH RAY GAARDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-656-0554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | D1829
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------