Basic Information
| Provider Information | |||||||||
| NPI: | 1376579938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 247 ROUTE 100 | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | SOMERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105893231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149628290 | ||||||||
| FaxNumber: | 9149628851 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 WHITE PLAINS RD | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | TARRYTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105915535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144938628 | ||||||||
| FaxNumber: | 9144938564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
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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 | 2088P0231X | 149688 | NY | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | 149688 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00715586 | 05 | NY | MEDICAID |