MEDICARE: MATTHEW J. GARDINER, MD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1588990279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTHEW J. GARDINER, MD, PC

Provider Business Mailing Address
First Line	:	1452 E RIDGELINE DR
Second Line	:	SUITE 151
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4946
Country	:	US
Telephone Number	:	801-475-1783
Fax Number	:	801-475-5777

Provider Business Practice Location Address
First Line	:	1452 E RIDGELINE DR
Second Line	:	SUITE 151
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4946
Country	:	US
Telephone Number	:	801-475-1783
Fax Number	:	801-475-5777

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW JAMES GARDINER
Credential	:	MD
Telephone Number	:	801-475-1783

Provider Enumeration Date	:	10/30/2009
Last Update Date	:	10/30/2009

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