MEDICARE: PETER GARDNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	024317	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	010027907CT01	OTHER	BC/BS ID #
2	25013	OTHER	OXFORD ID #
3	061246885	OTHER	UNITED HEATLHCARE ID #
4	4125202	OTHER	AETNA
5	020183	OTHER	HEALTHNET ID #
6	024317	OTHER	CT CARE ID #

General Provider Information

NPI Number	:	1972590578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER GARDNER M.D.

Provider Business Mailing Address
First Line	:	92 JORDAN LANE
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903
Country	:	US
Telephone Number	:	203-940-2995
Fax Number	:	203-547-6194

Provider Business Practice Location Address
First Line	:	92 JORDAN LN
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903-3914
Country	:	US
Telephone Number	:	203-940-2995
Fax Number	:	203-547-6194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	03/21/2016

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