Provider Demographics
NPI:1043421134
Name:GARDNER, DAVE (PT)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 NORTH COMMONS LOOP
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-3577
Mailing Address - Country:US
Mailing Address - Phone:205-752-0845
Mailing Address - Fax:205-752-0866
Practice Address - Street 1:1781 NORTH COMMONS LOOP
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-3577
Practice Address - Country:US
Practice Address - Phone:205-752-0845
Practice Address - Fax:205-752-0866
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTA763OtherALABAMA PT LICENSE NUMBER
AL51527979OtherBCBS PROVIDER NUMBER