Provider Demographics
NPI:1932165321
Name:GARDNER, GLENN PIERCE (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:PIERCE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:STE 3002
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-534-9194
Practice Address - Fax:814-534-5847
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200504000082086S0129X
WAMD 601188242086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001543260Medicaid
MO259599OtherHEALTHLINK
MO202277OtherBLUE SHIELD/BLUE CHOICE
MO206237307Medicaid
F54856Medicare UPIN
PA456786ZH9AMedicare PIN
MOP00415583Medicare PIN
MO202277OtherBLUE SHIELD/BLUE CHOICE
MO206237307Medicaid
MOP00312945Medicare PIN