Healthcare Provider Details

I. General information

NPI: 1790768406
Provider Name (Legal Business Name): S. AURORA GARDNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 E STATE ROAD 44 SUITE 4
CONNERSVILLE IN
47331-8374
US

IV. Provider business mailing address

1100 REID PKWY MEDICAL STAFF SERVICES
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-6612
  • Fax: 765-827-6910
Mailing address:
  • Phone: 765-827-6612
  • Fax: 765-827-6910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01041571
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: