Basic Information
| Provider Information | |||||||||
| NPI: | 1619973963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANTT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37229 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404855200 | ||||||||
| FaxNumber: | 3016256906 | ||||||||
| Practice Location | |||||||||
| Address1: | 9420 KEY WEST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012519555 | ||||||||
| FaxNumber: | 3013090765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | D41612 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 751141800 | 05 | MD | MEDICAID |