MEDICARE: RODERICK LEE EDWARDS II

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	172A00000X	Driver

General Provider Information

NPI Number	:	1780216929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODERICK LEE EDWARDS II

Provider Business Mailing Address
First Line	:	5724 BENSON DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70812-2603
Country	:	US
Telephone Number	:	225-371-4203
Fax Number	:

Provider Business Practice Location Address
First Line	:	5724 BENSON DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70812-2603
Country	:	US
Telephone Number	:	225-371-4203
Fax Number	:

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

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	02/05/2020

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