Basic Information
| Provider Information | |||||||||
| NPI: | 1255319463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 202 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774062916 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3061 S MARYLAND PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027312888 | ||||||||
| FaxNumber: | 7026969289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 12/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 6324 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200290213 | 05 | NV | MEDICAID | NV1309 | 01 | NV | BLUE | OTHER |