MEDICARE: JANE EDMISTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1746	OTHER	NC	LICENSE #

General Provider Information

NPI Number	:	1235246042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE EDMISTON

Provider Business Mailing Address
First Line	:	7013 W DUNCAN RD
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-8742
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 SAM NEWELL RD STE 201
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-7594
Country	:	US
Telephone Number	:	704-814-4479
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2007

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Directions to “ JANE EDMISTON ” Practice Location

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