MEDICARE: MR. PHILLIP W EDMONDS JR. CSA

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	246ZC0007X	Surgical Assistant	138187	TX

General Provider Information

NPI Number	:	1265771570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILLIP W EDMONDS JR. CSA

Provider Business Mailing Address
First Line	:	9955 KEMPWOOD DR
Second Line	:	APT 804
City	:	HOUSTON
State	:	TX
Zip	:	77080-2668
Country	:	US
Telephone Number	:	832-723-7692
Fax Number	:

Provider Business Practice Location Address
First Line	:	9955 KEMPWOOD DR
Second Line	:	APT 804
City	:	HOUSTON
State	:	TX
Zip	:	77080-2668
Country	:	US
Telephone Number	:	832-723-7692
Fax Number	:

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

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	02/06/2013

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