MEDICARE: ROBERT EARL GARDNER JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0600X	Clinical Neurophysiology Physician	2005004436	MO
2	2084N0400X	Neurology Physician	2005004436	MO

General Provider Information

NPI Number	:	1649365917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT EARL GARDNER JR. MD

Provider Business Mailing Address
First Line	:	1359 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1727
Country	:	US
Telephone Number	:	573-651-3188
Fax Number	:	573-651-3048

Provider Business Practice Location Address
First Line	:	1359 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-1727
Country	:	US
Telephone Number	:	573-651-3188
Fax Number	:	573-651-3048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	06/26/2024

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