Healthcare Provider Details

I. General information

NPI: 1003476367
Provider Name (Legal Business Name): GAIL SAMDPERIL EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 SOUND BEACH AVE
OLD GREENWICH CT
06870-2222
US

IV. Provider business mailing address

398 SOUND BEACH AVE
OLD GREENWICH CT
06870-2222
US

V. Phone/Fax

Practice location:
  • Phone: 203-698-8869
  • Fax:
Mailing address:
  • Phone: 203-698-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000230
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: