Healthcare Provider Details

I. General information

NPI: 1821619768
Provider Name (Legal Business Name): MICHAEL JAMES GUDDENDORF ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 N 27TH ST
DECATUR IL
62526-2191
US

IV. Provider business mailing address

1276 OAKLEAF CT
AURORA IL
60506-1676
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-4249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096004843
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: