MEDICARE: DR. GREGG RONALD SCUDERO DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X0069801	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C069809W	OTHER		WORKERS COMP

General Provider Information

NPI Number	:	1073590741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG RONALD SCUDERO DC

Provider Business Mailing Address
First Line	:	5912 FLATLANDS AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-1808
Country	:	US
Telephone Number	:	718-444-8500
Fax Number	:	718-444-8505

Provider Business Practice Location Address
First Line	:	5912 FLATLANDS AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-1808
Country	:	US
Telephone Number	:	718-444-8500
Fax Number	:	718-444-8505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2005
Last Update Date	:	02/26/2009

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