Provider Demographics
NPI:1053436311
Name:AMDUR CHIROPRACTIC PC
Entity type:Organization
Organization Name:AMDUR CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:AMDUR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-321-6300
Mailing Address - Street 1:194 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2804
Mailing Address - Country:US
Mailing Address - Phone:631-321-6300
Mailing Address - Fax:631-321-6338
Practice Address - Street 1:194 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2804
Practice Address - Country:US
Practice Address - Phone:631-321-6300
Practice Address - Fax:631-321-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXDW901Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER