MEDICARE: PAIN INSTITUTE OF CHARLESTON, LLC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1346821766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN INSTITUTE OF CHARLESTON, LLC

Provider Business Mailing Address
First Line	:	353 ASHLEY AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-4684
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1014 SAINT ANDREWS BLVD STE 210A
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-7177
Country	:	US
Telephone Number	:	843-805-2628
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JONATHAN PARKS GARDNER
Credential	:	MD
Telephone Number	:	843-805-2628

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	01/07/2022

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