=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356785455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN GARDNER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2013
-----------------------------------------------------
Last Update Date | 10/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 LEE ST BOX 800719
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22908-0816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-924-2150
-----------------------------------------------------
Fax | 434-982-1530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 LEE ST BOX 800719
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22908-0816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-924-2150
-----------------------------------------------------
Fax | 434-982-1530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 82070
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------