MEDICARE: EDWIGE GOBY KONWO-TAYO

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	207P00000X	Emergency Medicine Physician	RN220667	GA
2	363LF0000X	Family Nurse Practitioner	RN220667	GA

General Provider Information

NPI Number	:	1538646526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWIGE GOBY KONWO-TAYO

Provider Business Mailing Address
First Line	:	814 LAZARUS DR
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-5100
Country	:	US
Telephone Number	:	404-825-6874
Fax Number	:

Provider Business Practice Location Address
First Line	:	1183 S HAIRSTON RD STE A
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2796
Country	:	US
Telephone Number	:	404-296-8858
Fax Number	:

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

Provider Enumeration Date	:	07/23/2018
Last Update Date	:	12/30/2019

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Directions to “ EDWIGE GOBY KONWO-TAYO ” Practice Location

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