Provider Demographics
NPI:1710089818
Name:GARDNER, GENE R (CRNA)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2157
Mailing Address - Country:US
Mailing Address - Phone:618-242-2317
Mailing Address - Fax:618-242-9710
Practice Address - Street 1:605 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2857
Practice Address - Country:US
Practice Address - Phone:618-241-1108
Practice Address - Fax:618-241-3805
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
L95807Medicare ID - Type Unspecified