Provider Demographics
NPI:1346246154
Name:GARDNER, MICHELE ANN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANN
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-0305
Mailing Address - Country:US
Mailing Address - Phone:517-266-0199
Mailing Address - Fax:517-266-0196
Practice Address - Street 1:1542 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1392
Practice Address - Country:US
Practice Address - Phone:517-266-0199
Practice Address - Fax:517-266-0196
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMG055976174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4530060Medicaid
MI1604610281OtherBCBS
MI1604610281OtherBCBS
MI4530060Medicaid