MEDICARE: RANDOLPH ANTHONY EDWARDS M.D.

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	208600000X	Surgery Physician	32957	MN
2	208600000X	Surgery Physician	MD60178868	WA

General Provider Information

NPI Number	:	1295711141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDOLPH ANTHONY EDWARDS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 340581
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-0581
Country	:	US
Telephone Number	:	507-279-2052
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 E 104TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4508
Country	:	US
Telephone Number	:	507-279-2052
Fax Number	:

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	02/13/2014

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