Provider Demographics
NPI:1356328108
Name:GARDEN, JACK L (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:GARDEN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:2422 S BROAD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4418
Mailing Address - Country:US
Mailing Address - Phone:215-389-1748
Mailing Address - Fax:215-389-0604
Practice Address - Street 1:2422 S BROAD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-389-1748
Practice Address - Fax:215-389-0604
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08143100207RC0000X
PAMD038681E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011409460002Medicaid
PA0011409460002Medicaid
PA406690Medicare PIN