Provider Demographics
NPI:1275038150
Name:GARDNER, SHELBY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 AUBURN AVENUE
Mailing Address - Street 2:ATTN: PAYOR ENROLLMENT 4-7
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219
Mailing Address - Country:US
Mailing Address - Phone:513-351-9900
Mailing Address - Fax:
Practice Address - Street 1:1955 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41011-2792
Practice Address - Country:US
Practice Address - Phone:859-341-6255
Practice Address - Fax:859-547-1197
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57360207Q00000X
OH35.140045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine