MEDICARE: JOHN GARDINER P.A.

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	363A00000X	Physician Assistant	50-00-0099	OH

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	:	1629174776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN GARDINER P.A.

Provider Business Mailing Address
First Line	:	4103 DECOURSEY AVE
Second Line	:
City	:	COVINGTON
State	:	KY
Zip	:	41015-1811
Country	:	US
Telephone Number	:	859-261-6383
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 PROGRESS PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-1715
Country	:	US
Telephone Number	:	513-346-5000
Fax Number	:	513-671-2003

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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