Healthcare Provider Details

I. General information

NPI: 1326029158
Provider Name (Legal Business Name): TRICIA KAYE GIFFORD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRICIA KAYE WARNER MD

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W GOELLER BLVD
COLUMBUS IN
47201-8308
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-375-3330
  • Fax: 812-375-3329
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36101716
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01063240
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: