Basic Information
| Provider Information | |||||||||
| NPI: | 1508032103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 08/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 52223 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 12961 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 18613 | 05 | ND | MEDICAID | ENROLLED | 05 | IA | MEDICAID | ENROLLED | 05 | WI | MEDICAID | ENROLLED | 05 | MN | MEDICAID |