Healthcare Provider Details

I. General information

NPI: 1639441454
Provider Name (Legal Business Name): MATTHEW GLENN HUNTER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CAMPUS ROAD
ANNANDALE-ON-HUDSON NY
12504
US

IV. Provider business mailing address

128 EAST STOUT AVE. PO BOX 262
PORT EWEN NY
12466
US

V. Phone/Fax

Practice location:
  • Phone: 845-758-7694
  • Fax:
Mailing address:
  • Phone: 859-582-5602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001936-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: