Basic Information
| Provider Information | |||||||||
| NPI: | 1003843897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598064907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413950 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WESY KENT | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598014008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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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 | 207Y00000X | 8225 | MT | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0101048 | 05 | MT | MEDICAID |