Basic Information
| Provider Information | |||||||||
| NPI: | 1124262472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARDNER | ||||||||
| OtherFirstName: | KEMBERLY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE BLDG 9 1ST FLOOR | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043650966 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21214 NORTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | CYPRESS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774293373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819495941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | P2242 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 83830 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.