MEDICARE: GARDNER & GARDNER, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	M6671	ID
2	207Q00000X	Family Medicine Physician	NP416A	ID
3	207Q00000X	Family Medicine Physician	M6670	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477551794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARDNER & GARDNER, PA

Provider Business Mailing Address
First Line	:	203 N A ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1201
Country	:	US
Telephone Number	:	208-983-3000
Fax Number	:	208-983-9276

Provider Business Practice Location Address
First Line	:	203 N A ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1201
Country	:	US
Telephone Number	:	208-983-3000
Fax Number	:	208-983-9276

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JIM GARDNER
Credential	:	MO
Telephone Number	:	208-983-3000

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	08/22/2020

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