Provider Demographics
NPI:1003843897
Name:GARDNER, PHILLIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
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:PO BOX 4907
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4907
Mailing Address - Country:US
Mailing Address - Phone:406-541-3277
Mailing Address - Fax:406-541-3950
Practice Address - Street 1:700 WESY KENT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4008
Practice Address - Country:US
Practice Address - Phone:406-541-3277
Practice Address - Fax:406-541-3950
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8225207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0101048Medicaid
MT0101048Medicaid
MT010001455Medicare ID - Type Unspecified