Basic Information
| Provider Information | |||||||||
| NPI: | 1851430177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDGERLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3512 HIGHWAY 365 | ||||||||
| Address2: | |||||||||
| City: | NEDERLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776277834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097227116 | ||||||||
| FaxNumber: | 4097227450 | ||||||||
| Practice Location | |||||||||
| Address1: | 3512 HIGHWAY 365 | ||||||||
| Address2: | |||||||||
| City: | NEDERLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776277834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097227116 | ||||||||
| FaxNumber: | 4097227450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 1072734 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.