Provider Demographics
NPI:1295806537
Name:HUDSON, JEREMY EDWIN (PT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:EDWIN
Last Name:HUDSON
Suffix:
Gender:M
Credentials:PT
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Other - Credentials:
Mailing Address - Street 1:209 COLUMBUS AVE
Mailing Address - Street 2:BASEMENT INSIDE BACK BAY CROSSFIT
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5109
Mailing Address - Country:US
Mailing Address - Phone:617-429-3577
Mailing Address - Fax:617-375-8581
Practice Address - Street 1:209 COLUMBUS AVE
Practice Address - Street 2:BASEMENT INSIDE BACK BAY CROSSFITS
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5109
Practice Address - Country:US
Practice Address - Phone:617-429-3577
Practice Address - Fax:617-375-8581
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA18342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000967001Medicare UPIN