1316912827 NPI number — MR. SCOTT DAVID GRUDER MSED, ATC, CSCS

Table of content: MR. SCOTT DAVID GRUDER MSED, ATC, CSCS (NPI 1316912827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316912827 NPI number — MR. SCOTT DAVID GRUDER MSED, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUDER
Provider First Name:
SCOTT
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSED, ATC, CSCS
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:
1316912827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 LONG TREE LN
Provider Second Line Business Mailing Address:
APT 18
Provider Business Mailing Address City Name:
MORICHES
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11955-2050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 W ROE BLVD
Provider Second Line Business Practice Location Address:
ST. JOSEPH'S COLLEGE JOHN A DANZI ATHLETIC CENTER
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-447-3330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2006

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: 2255A2300X , with the licence number:  001091 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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