Basic Information
| Provider Information | |||||||||
| NPI: | 1205865979 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWATER MEDICAL ASSOCIATES PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDGEWATER MEDICAL CENTER AND URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | LILLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275466690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108934111 | ||||||||
| FaxNumber: | 9108939850 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | LILLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275466690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108934111 | ||||||||
| FaxNumber: | 9108939850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | REYES | ||||||||
| AuthorizedOfficialFirstName: | RODOLFO | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9108934111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDGEWATER MEDICAL ASSOCIATES PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.