1295806537 NPI number — MR. JEREMY EDWIN HUDSON PT

Table of content: MR. JEREMY EDWIN HUDSON PT (NPI 1295806537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295806537 NPI number — MR. JEREMY EDWIN HUDSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDSON
Provider First Name:
JEREMY
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295806537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 COLUMBUS AVE
Provider Second Line Business Mailing Address:
BASEMENT INSIDE BACK BAY CROSSFIT
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02116-5109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-429-3577
Provider Business Mailing Address Fax Number:
617-375-8581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 COLUMBUS AVE
Provider Second Line Business Practice Location Address:
BASEMENT INSIDE BACK BAY CROSSFITS
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02116-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-429-3577
Provider Business Practice Location Address Fax Number:
617-375-8581
Provider Enumeration Date:
11/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  18342 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)