MEDICARE: GREGORY PHILLIP GARDNER M.D.

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	207R00000X	Internal Medicine Physician	R76101	AZ
2	207R00000X	Internal Medicine Physician	11782249-1205	UT

General Provider Information

NPI Number	:	1750816161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY PHILLIP GARDNER M.D.

Provider Business Mailing Address
First Line	:	1492 W ANTELOPE DR STE 203
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-1141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1492 W ANTELOPE DR STE 203
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-1141
Country	:	US
Telephone Number	:	801-807-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2017
Last Update Date	:	06/03/2020

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