Provider Demographics
NPI:1043684889
Name:MICHAEL P. GARDNER, MD PC
Entity Type:Organization
Organization Name:MICHAEL P. GARDNER, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-783-0208
Mailing Address - Street 1:19260 SW 65TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5710
Mailing Address - Country:US
Mailing Address - Phone:503-692-1200
Mailing Address - Fax:503-692-1220
Practice Address - Street 1:19260 SW 65TH AVE STE 310
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5710
Practice Address - Country:US
Practice Address - Phone:503-692-1200
Practice Address - Fax:503-692-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22270261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288387Medicaid
ORH14054Medicare UPIN