Basic Information
| Provider Information | |||||||||
| NPI: | 1629066154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAGE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CERNY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36351 | ||||||||
| Address2: | SOUTHEAST ANESTHESIOLOGY CONSULTANTS PA | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282366351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043775772 | ||||||||
| FaxNumber: | 7043773389 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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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 | 207L00000X | 9300390 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 042.0014182 | VT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | N00390 | 01 | SC | MEDICAID | OTHER | 8911269 | 05 | NC | MEDICAID |