Provider Demographics
NPI:1902954522
Name:MAURICE R GARDNER DPM PA
Entity Type:Organization
Organization Name:MAURICE R GARDNER DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-784-2042
Mailing Address - Street 1:681 SABATTUS ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-3829
Mailing Address - Country:US
Mailing Address - Phone:207-784-2042
Mailing Address - Fax:
Practice Address - Street 1:681 SABATTUS ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-3829
Practice Address - Country:US
Practice Address - Phone:207-784-2042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME121590000Medicaid
ME0002494Medicare PIN