MEDICARE: GREGORY J 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	225100000X	Physical Therapist	104149-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	104149-2401	OTHER	UT	STATE LICENSE

General Provider Information

NPI Number	:	1528063575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY J GARDNER

Provider Business Mailing Address
First Line	:	9350 S 150 E
Second Line	:	#460
City	:	SANDY
State	:	UT
Zip	:	84070-2702
Country	:	US
Telephone Number	:	801-255-4999
Fax Number	:	801-748-1865

Provider Business Practice Location Address
First Line	:	9350 S 150 E
Second Line	:	#460
City	:	SANDY
State	:	UT
Zip	:	84070-2702
Country	:	US
Telephone Number	:	801-255-4999
Fax Number	:	801-748-1865

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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Directions to “ GREGORY J GARDNER ” Practice Location

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