MEDICARE: MAKAYLA ANNE GARDNER

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	208100000X	Physical Medicine & Rehabilitation Physician	11686	SC

General Provider Information

NPI Number	:	1356055446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKAYLA ANNE GARDNER

Provider Business Mailing Address
First Line	:	16 OAKHURST AVE APT A
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29609-5487
Country	:	US
Telephone Number	:	916-955-2962
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 HAMPTON AVENUE EXT STE 11B
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-1168
Country	:	US
Telephone Number	:	864-900-2975
Fax Number	:

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

Provider Enumeration Date	:	01/12/2023
Last Update Date	:	01/19/2023

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