=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437216876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALAN GARDNER MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 05/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 WINDY HILL RD SE 220
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-8665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-335-8638
-----------------------------------------------------
Fax | 909-335-8644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 402904
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30384-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALAN GARDNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-335-8638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------