Provider Demographics
NPI:1710948609
Name:GARDNER, SHYRELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYRELLE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W MOUNT PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2904
Mailing Address - Country:US
Mailing Address - Phone:215-247-3300
Mailing Address - Fax:216-247-0799
Practice Address - Street 1:333 W MOUNT PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2904
Practice Address - Country:US
Practice Address - Phone:215-247-3300
Practice Address - Fax:216-247-0799
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030003E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000934124Medicaid
PAC34154Medicare UPIN
PA000934124Medicaid