MEDICARE: VINCENT WAYNE GARDNER M.D.

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	202K00000X	Phlebology Physician	46227	TN
2	208600000X	Surgery Physician	46227	TN
3	202K00000X	Phlebology Physician	061073	GA
4	208600000X	Surgery Physician	061073	GA

General Provider Information

NPI Number	:	1962476358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT WAYNE GARDNER M.D.

Provider Business Mailing Address
First Line	:	1405 COWART ST
Second Line	:	SUITE 321
City	:	CHATTANOOGA
State	:	TN
Zip	:	37408-1127
Country	:	US
Telephone Number	:	423-551-8346
Fax Number	:	423-551-8347

Provider Business Practice Location Address
First Line	:	1405 COWART ST
Second Line	:	SUITE 321
City	:	CHATTANOOGA
State	:	TN
Zip	:	37408-1127
Country	:	US
Telephone Number	:	423-551-8346
Fax Number	:	423-551-8347

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

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	05/09/2016

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