Healthcare Provider Details

I. General information

NPI: 1164452595
Provider Name (Legal Business Name): MICHAEL P GARDNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-1994
  • Fax: 740-376-1940
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number34008378
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: