Healthcare Provider Details

I. General information

NPI: 1275038150
Provider Name (Legal Business Name): SHELBY MICHAEL GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 DIXIE HWY
FT WRIGHT KY
41011-2792
US

IV. Provider business mailing address

2139 AUBURN AVENUE ATTN: PAYOR ENROLLMENT 4-7
CINCINNATI OH
45219
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-6255
  • Fax: 859-547-1197
Mailing address:
  • Phone: 513-351-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57360
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: