Basic Information
| Provider Information | |||||||||
| NPI: | 1043421134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | DAVE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1781 NORTH COMMONS LOOP | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354063577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057520845 | ||||||||
| FaxNumber: | 2057520866 | ||||||||
| Practice Location | |||||||||
| Address1: | 1781 NORTH COMMONS LOOP | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354063577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057520845 | ||||||||
| FaxNumber: | 2057520866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH763 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PTA763 | 01 | AL | ALABAMA PT LICENSE NUMBER | OTHER | 51527979 | 01 | AL | BCBS PROVIDER NUMBER | OTHER |