Healthcare Provider Details

I. General information

NPI: 1285630061
Provider Name (Legal Business Name): ERIN SCOTT GARDNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2005
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 300A
SAINT LOUIS MO
63131-2354
US

IV. Provider business mailing address

PO BOX 31236
SAINT LOUIS MO
63131-0236
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-7546
  • Fax: 314-997-7558
Mailing address:
  • Phone: 314-997-7546
  • Fax: 314-997-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2001005039
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number2001005039
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2001005039
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: