Healthcare Provider Details

I. General information

NPI: 1770572810
Provider Name (Legal Business Name): ROSS E GARDNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 TUSCALOOSA AVENUE SW
BIRMINGHAM AL
35211-1486
US

IV. Provider business mailing address

401 TUSCALOOSA AVENUE SW
BIRMINGHAM AL
35211-1486
US

V. Phone/Fax

Practice location:
  • Phone: 205-780-9655
  • Fax: 205-780-9623
Mailing address:
  • Phone: 205-780-9655
  • Fax: 205-780-9623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number00011281
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number11281
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: