Basic Information
| Provider Information | |||||||||
| NPI: | 1871539049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDZIOLA | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | SUITE B350 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644544500 | ||||||||
| FaxNumber: | 8644544505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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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 | 204D00000X | 1111 | SC | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | P00607536 | 01 | SC | RR MEDICARE | OTHER | 011114 | 05 | SC | MEDICAID | 576007863203 | 01 | SC | BCBS OF SC | OTHER |