1568458701 NPI number — DR. SCOTT ALLAN GARDNER MD

Table of content: DR. SCOTT ALLAN GARDNER MD (NPI 1568458701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568458701 NPI number — DR. SCOTT ALLAN GARDNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
SCOTT
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568458701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 E ALEX BELL RD
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-254-3121
Provider Business Mailing Address Fax Number:
937-999-4174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 E ALEX BELL RD
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-254-3121
Provider Business Practice Location Address Fax Number:
937-999-4174
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD16480 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: M9619 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD00046059 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 35.054539 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1568458701 . This is a "REGENCE BLUESHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1568458701 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0212253 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 76714 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00815199 . This is a "MEDICARE RR - WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 012554 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013432 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134119 . This is a "DMERC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00349485 . This is a "MEDICARE -RR - IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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