Healthcare Provider Details

I. General information

NPI: 1477551794
Provider Name (Legal Business Name): GARDNER & GARDNER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N A ST
GRANGEVILLE ID
83530-1201
US

IV. Provider business mailing address

203 N A ST
GRANGEVILLE ID
83530-1201
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-3000
  • Fax: 208-983-9276
Mailing address:
  • Phone: 208-983-3000
  • Fax: 208-983-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6671
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNP416A
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6670
License Number StateID

VIII. Authorized Official

Name: DR. JIM GARDNER
Title or Position: PRESIDENT
Credential: MO
Phone: 208-983-3000