Provider Demographics
NPI:1316912827
Name:GRUDER, SCOTT DAVID (MSED, ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:GRUDER
Suffix:
Gender:M
Credentials:MSED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 LONG TREE LN
Mailing Address - Street 2:APT 18
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 W ROE BLVD
Practice Address - Street 2:ST. JOSEPH'S COLLEGE JOHN A DANZI ATHLETIC CENTER
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2325
Practice Address - Country:US
Practice Address - Phone:631-447-3330
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0010912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer