Provider Demographics
NPI:1245525476
Name:SCUDERI, PHILIP JOSEPH (COTA)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:SCUDERI
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 33RD ST
Mailing Address - Street 2:500
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2329
Mailing Address - Country:US
Mailing Address - Phone:212-589-1213
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST
Practice Address - Street 2:500
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:212-589-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006019-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1733607631Medicare NSC