Provider Demographics
NPI:1255319463
Name:GARDNER, KELLY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROBERT
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 202
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:
Practice Address - Street 1:3061 S MARYLAND PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2298
Practice Address - Country:US
Practice Address - Phone:702-731-2888
Practice Address - Fax:702-696-9289
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV63242085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200290213Medicaid
NVNV1309OtherBLUE
E84941Medicare UPIN
NV200290213Medicaid
NV300061559Medicare UPIN