MEDICARE: GREGORY BOYLE ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1508429309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY BOYLE ATC

Provider Business Mailing Address
First Line	:	1300 FRANKLIN AVE STE LL2
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-1760
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11050 71ST RD APT 4A
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4973
Country	:	US
Telephone Number	:	718-689-2340
Fax Number	:

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

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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