Provider Demographics
NPI:1790768406
Name:GARDNER, S. AURORA (MD)
Entity Type:Individual
Prefix:
First Name:S.
Middle Name:AURORA
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-827-6612
Mailing Address - Fax:765-827-6910
Practice Address - Street 1:1473 E STATE ROAD 44
Practice Address - Street 2:SUITE 4
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8374
Practice Address - Country:US
Practice Address - Phone:765-827-6612
Practice Address - Fax:765-827-6910
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000705719OtherANTHEM
IN100388460Medicaid
000000705719OtherANTHEM