Provider Demographics
NPI:1861895930
Name:MARCUS A GARDINER
Entity type:Organization
Organization Name:MARCUS A GARDINER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:231-225-5216
Mailing Address - Street 1:10053 SINGER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BARODA
Mailing Address - State:MI
Mailing Address - Zip Code:49101-9713
Mailing Address - Country:US
Mailing Address - Phone:231-225-5216
Mailing Address - Fax:
Practice Address - Street 1:10053 SINGER LAKE RD
Practice Address - Street 2:
Practice Address - City:BARODA
Practice Address - State:MI
Practice Address - Zip Code:49101-9713
Practice Address - Country:US
Practice Address - Phone:231-225-5216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty