Provider Demographics
NPI:1568458701
Name:GARDNER, SCOTT ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:175 E ALEX BELL RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:509-254-3121
Mailing Address - Fax:937-999-4174
Practice Address - Street 1:175 E ALEX BELL RD
Practice Address - Street 2:SUITE 212
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:509-254-3121
Practice Address - Fax:937-999-4174
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD16480208600000X
IDM9619208600000X
WAMD00046059208600000X
OH35.054539208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1568458701OtherREGENCE BLUESHIELD OF IDAHO
ID1568458701Medicaid
WA0212253OtherLABOR & INDUSTRY
ID76714OtherBLUE CROSS
WAP00815199OtherMEDICARE RR - WA
OR012554Medicaid
WA1013432Medicaid
ID1134119OtherDMERC
IDP00349485OtherMEDICARE -RR - IDAHO
WA0212253OtherLABOR & INDUSTRY
WAP00815199OtherMEDICARE RR - WA
ID1134119Medicare PIN