Healthcare Provider Details

I. General information

NPI: 1053345934
Provider Name (Legal Business Name): CRAIG JOSEPH GARDNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 INDUSTRIAL BLVD STE 204
PAOLI PA
19301-1620
US

IV. Provider business mailing address

11 INDUSTRIAL BLVD SUITE 204
PAOLI PA
19301-1632
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-6251
  • Fax: 610-644-1440
Mailing address:
  • Phone: 610-644-6251
  • Fax: 610-644-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberOS012630
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: