MEDICARE: FREDRICK ANTHONY GARDIN ATC, CSCS, USAW

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	2255A2300X	Athletic Trainer	788	SC

General Provider Information

NPI Number	:	1205933454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDRICK ANTHONY GARDIN ATC, CSCS, USAW

Provider Business Mailing Address
First Line	:	500 HARBISON BLVD
Second Line	:	APT 2310
City	:	COLUMBIA
State	:	SC
Zip	:	29212-1735
Country	:	US
Telephone Number	:	803-673-6155
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 HARBISON BLVD
Second Line	:	APT 2310
City	:	COLUMBIA
State	:	SC
Zip	:	29212-1735
Country	:	US
Telephone Number	:	803-673-6155
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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