Provider Demographics
NPI:1770572810
Name:GARDNER, ROSS E (MD)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:E
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 1:401 TUSCALOOSA AVENUE SW
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-1486
Mailing Address - Country:US
Mailing Address - Phone:205-780-9655
Mailing Address - Fax:205-780-9623
Practice Address - Street 1:401 TUSCALOOSA AVENUE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1486
Practice Address - Country:US
Practice Address - Phone:205-780-9655
Practice Address - Fax:205-780-9623
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00011281207Y00000X
AL11281207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000013673Medicaid