Provider Demographics
NPI:1083620041
Name:GARDNER, GARY ROSCOE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROSCOE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 WINDY WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1360
Mailing Address - Country:US
Mailing Address - Phone:502-241-6730
Mailing Address - Fax:502-253-9933
Practice Address - Street 1:13106 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1572
Practice Address - Country:US
Practice Address - Phone:502-253-0025
Practice Address - Fax:502-253-9933
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000347132OtherBCBS PROVIDER NUMBER
KY50005767Medicaid
KY650593OtherUNITED HEALTH CARE NUMBER
KY7135162OtherAETNA PROVIDER NUMBER
KY3428389OtherCIGNA PROVIDER NUMBER
KY50005767Medicaid