Provider Demographics
NPI:1316054133
Name:GARDNER, BEN A (MD)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-380-0075
Mailing Address - Fax:931-388-7502
Practice Address - Street 1:854 W JAMES CAMPBELL BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4659
Practice Address - Country:US
Practice Address - Phone:931-380-0075
Practice Address - Fax:931-388-7502
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17712207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3024573Medicaid
TN3154189OtherBCBSTN
TN3710089Medicaid
TN3710089Medicaid
3024574Medicare PIN
TN110212604Medicare PIN
TN3024573Medicaid
TN3154189OtherBCBSTN