MEDICARE: EVAN WALTER GRUNDER 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	38MC00777800	NJ

General Provider Information

NPI Number	:	1467043646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN WALTER GRUNDER DC

Provider Business Mailing Address
First Line	:	1555 ANN ST
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-2606
Country	:	US
Telephone Number	:	607-242-6913
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 MONROE ST STE C208
Second Line	:
City	:	HOBOKEN
State	:	NJ
Zip	:	07030-6350
Country	:	US
Telephone Number	:	201-535-2476
Fax Number	:

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

Provider Enumeration Date	:	01/29/2021
Last Update Date	:	01/29/2021

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