Healthcare Provider Details

I. General information

NPI: 1164462602
Provider Name (Legal Business Name): BRADFORD P GARNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S HUDSON AVE
AURORA MO
65605-2362
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-678-5176
  • Fax: 417-678-0675
Mailing address:
  • Phone: 417-820-0289
  • Fax: 417-820-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6533
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009001435
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: