Provider Demographics
NPI:1336521194
Name:GARDNER, KATIE ELLEN (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELLEN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 WEST GRAND BLVD
Mailing Address - Street 2:ATTENTION:L K17, PULMONARY AND CRITICAL CARE MEDICINE
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2600
Mailing Address - Fax:313-916-9102
Practice Address - Street 1:2799 WEST GRAND BLVD
Practice Address - Street 2:ATTENTION:L K17, PULMONARY AND CRITICAL CARE MEDICINE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:313-916-9102
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine