Provider Demographics
NPI:1710976352
Name:GARDNER, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-845-5672
Mailing Address - Fax:502-845-1402
Practice Address - Street 1:150 FAIRVIEW COURT
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019
Practice Address - Country:US
Practice Address - Phone:502-845-5672
Practice Address - Fax:502-845-1402
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22049208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64220494Medicaid
KY00000048271OtherANTHEM
00000048271OtherANTHEM
0100485OtherUHC
00000048271OtherANTHEM
0092611Medicare ID - Type Unspecified
C69049Medicare UPIN
KY64220494Medicaid