Provider Demographics
NPI:1154494862
Name:S AURORA GARDNER M D LLC
Entity Type:Organization
Organization Name:S AURORA GARDNER M D LLC
Other - Org Name:S. AURORA GARDNER, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:S.
Authorized Official - Middle Name:AURORA
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-827-6612
Mailing Address - Street 1:1473 E STATE ROAD 44 STE 4
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-8292
Mailing Address - Country:US
Mailing Address - Phone:765-827-6612
Mailing Address - Fax:765-827-6910
Practice Address - Street 1:1473 E STATE ROAD 44 STE 4
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8292
Practice Address - Country:US
Practice Address - Phone:765-827-6612
Practice Address - Fax:765-827-6910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
180960Medicare PIN
INF83571Medicare UPIN