Healthcare Provider Details

I. General information

NPI: 1619382744
Provider Name (Legal Business Name): JESSICA LAUREN EDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 HARLEM RD
CHEEKTOWAGA NY
14225-4018
US

IV. Provider business mailing address

62043 COLLEEN CT
WASHINGTON MI
48094-1000
US

V. Phone/Fax

Practice location:
  • Phone: 716-891-2400
  • Fax:
Mailing address:
  • Phone: 248-225-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125065518
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number289530
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301113955
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: