MEDICARE: JEREMY TODD EDMONDS D.O.

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	A-1270-04	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080165527	OTHER	NM	RAILROAD MEDICARE NUMBER

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	:	1932116472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY TODD EDMONDS D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1520
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035-1520
Country	:	US
Telephone Number	:	505-832-4434
Fax Number	:	505-832-5024

Provider Business Practice Location Address
First Line	:	1108 CENTRAL AVE SW
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035-1520
Country	:	US
Telephone Number	:	505-832-4434
Fax Number	:	505-832-5024

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/09/2007

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