=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003476367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAIL SAMDPERIL EDD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2019
-----------------------------------------------------
Last Update Date | 06/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 398 SOUND BEACH AVE
-----------------------------------------------------
City | OLD GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06870-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-698-8869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 398 SOUND BEACH AVE
-----------------------------------------------------
City | OLD GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06870-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-698-8869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 000230
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------