Healthcare Provider Details

I. General information

NPI: 1841397916
Provider Name (Legal Business Name): MICHAEL J GARDNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/14/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2273
  • Fax: 573-884-4609
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006023034
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20060213034
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number2006023034
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: