Basic Information
| Provider Information | |||||||||
| NPI: | 1316054133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313800075 | ||||||||
| FaxNumber: | 9313887502 | ||||||||
| Practice Location | |||||||||
| Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313800075 | ||||||||
| FaxNumber: | 9313887502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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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 | 207R00000X | 17712 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 17712 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3024573 | 05 | TN | MEDICAID | 3154189 | 01 | TN | BCBSTN | OTHER | 3710089 | 05 | TN | MEDICAID |