Provider Demographics
NPI:1225220379
Name:TIMOTHY L. GARDNER, DPM,PC
Entity Type:Organization
Organization Name:TIMOTHY L. GARDNER, DPM,PC
Other - Org Name:MIDDLESBORO FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-248-2739
Mailing Address - Street 1:10810 PARKSIDE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1981
Mailing Address - Country:US
Mailing Address - Phone:865-218-7474
Mailing Address - Fax:865-218-7475
Practice Address - Street 1:123 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2865
Practice Address - Country:US
Practice Address - Phone:606-248-2739
Practice Address - Fax:606-248-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30924213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351921Medicaid
KY80002017Medicaid
TN0191729OtherBCBS
KY000000053556OtherBCBS
KY2012301Medicare PIN
TN0191729OtherBCBS
TN4138170001Medicare NSC
KY4138170001Medicare NSC
TN3351921Medicare PIN