1518938372 NPI number — EDGEWATER INTERNAL MEDICINE ASSOC. INC.

Table of content: (NPI 1518938372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518938372 NPI number — EDGEWATER INTERNAL MEDICINE ASSOC. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWATER INTERNAL MEDICINE ASSOC. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1518938372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2568 SOUTH RIDGEWOOD AVE
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
EDGEWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32111-7535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-428-4640
Provider Business Mailing Address Fax Number:
386-426-1409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2568 S. RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32141-7535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-428-4640
Provider Business Practice Location Address Fax Number:
386-426-1409
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
386-428-4640

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME0063341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23541 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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