Healthcare Provider Details

I. General information

NPI: 1104638790
Provider Name (Legal Business Name): SCOTT CHRISTOPHER GUNDERMAN PROVIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 TUXEDO AVE
PARMA OH
44134-1737
US

IV. Provider business mailing address

1621 TUXEDO AVE
PARMA OH
44134-1737
US

V. Phone/Fax

Practice location:
  • Phone: 216-450-7171
  • Fax:
Mailing address:
  • Phone: 216-450-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: