MEDICARE: MR. GERARD M. GINGRAS 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	001155-1	NY

General Provider Information

NPI Number	:	1093778383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERARD M. GINGRAS ATC

Provider Business Mailing Address
First Line	:	10 UPPER COLLEGE DR
Second Line	:	ALFRED STATE COLLEGE
City	:	ALFRED
State	:	NY
Zip	:	14802-1153
Country	:	US
Telephone Number	:	607-587-4388
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 UPPER COLLEGE DR
Second Line	:	ALFRED STATE COLLEGE
City	:	ALFRED
State	:	NY
Zip	:	14802-1153
Country	:	US
Telephone Number	:	607-587-4388
Fax Number	:

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

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	04/01/2015

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