Provider Demographics
NPI:1578630117
Name:GUNDERSON, ERIC ROBERT (MS, ATC, OTC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ROBERT
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:MS, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 JENNYS ROW
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3420
Mailing Address - Country:US
Mailing Address - Phone:706-248-1405
Mailing Address - Fax:
Practice Address - Street 1:59 EXECUTIVE PARK S
Practice Address - Street 2:EMORY ORTHOPAEDIC AND SPINE CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2208
Practice Address - Country:US
Practice Address - Phone:404-778-7137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0013862255A2300X
GA11-0624246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant