1295716660 NPI number — JON H EDWARDS MD

Table of content: JON H EDWARDS MD (NPI 1295716660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295716660 NPI number — JON H EDWARDS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
JON
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295716660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23625 COMMERCE PARK
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-255-5701
Provider Business Mailing Address Fax Number:
216-255-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
771 WEST END AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10025-5572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-255-5700
Provider Business Practice Location Address Fax Number:
216-255-5701
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  130277 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00729680 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7201480 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807444100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124078 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2650215 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 784T9 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 34195845144193 . This is a "TRICARE WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00285375 . This is a "RXR MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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