Provider Demographics
NPI:1538480777
Name:GARDNER, STEPHANIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SIEVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5262 CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3181
Mailing Address - Country:US
Mailing Address - Phone:210-241-0651
Mailing Address - Fax:
Practice Address - Street 1:5262 CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3181
Practice Address - Country:US
Practice Address - Phone:210-241-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11015553A390200000X
IN01070246A390200000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01366963OtherRAILROAD MEDICARE
IN201075650Medicaid
INP01137553Medicare PIN
IN232650003Medicare PIN
IN201075650Medicaid
IN259240004Medicare PIN
INP01366963OtherRAILROAD MEDICARE
INM400074923Medicare PIN