MEDICARE: CHRISTOPHER JOSEPH GREGORY MED, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	104.0133074	VT
2	2255A2300X	Athletic Trainer	0126002623	VA
3	2255A2300X	Athletic Trainer	003996	NY

General Provider Information

NPI Number	:	1083191837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER JOSEPH GREGORY MED, ATC

Provider Business Mailing Address
First Line	:	14 SAGEBRUSH LN
Second Line	:
City	:	KINGS PARK
State	:	NY
Zip	:	11754-3934
Country	:	US
Telephone Number	:	631-873-5605
Fax Number	:

Provider Business Practice Location Address
First Line	:	631 HOWARD AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4422
Country	:	US
Telephone Number	:	718-390-3100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	12/05/2022

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