MEDICARE: RYAN MACKENZIE GARDNER MD

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	207LC0200X	Critical Care Medicine (Anesthesiology) Physician	72062	MA
2	207P00000X	Emergency Medicine Physician	271295	MA

General Provider Information

NPI Number	:	1588195333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MACKENZIE GARDNER MD

Provider Business Mailing Address
First Line	:	75 PETERBOROUGH ST APT 501
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02215-4314
Country	:	US
Telephone Number	:	518-331-5012
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 BROOKLINE AVE
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02215-5400
Country	:	US
Telephone Number	:	617-667-7000
Fax Number	:

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

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	01/22/2026

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