Basic Information
| Provider Information | |||||||||
| NPI: | 1295716660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23625 COMMERCE PARK | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555701 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Practice Location | |||||||||
| Address1: | 771 WEST END AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100255572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162555700 | ||||||||
| FaxNumber: | 2162555701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 130277 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00729680 | 05 | NY | MEDICAID | 7201480 | 05 | SD | MEDICAID | 807444100 | 05 | ID | MEDICAID | 124078 | 05 | AZ | MEDICAID | 2650215 | 05 | OH | MEDICAID | 784T9 | 01 | NY | BCBS | OTHER | 34195845144193 | 01 | TRICARE WEST | OTHER | P00285375 | 01 | NY | RXR MEDICARE | OTHER |