MEDICARE: EDISON FAMILY PRACTICE

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	207Q00000X	Family Medicine Physician	MA45007	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548546286
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDISON FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	616 GROVE AVE
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08820-3212
Country	:	US
Telephone Number	:	732-548-6303
Fax Number	:	732-549-4676

Provider Business Practice Location Address
First Line	:	616 GROVE AVE
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08820-3212
Country	:	US
Telephone Number	:	732-548-6303
Fax Number	:	732-549-4676

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARIA S FLORES DIEPPA
Credential	:	MD
Telephone Number	:	732-548-6303

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	01/11/2012

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Directions to “EDISON FAMILY PRACTICE ” Practice Location

Language	Start Address	Practice Location

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