Healthcare Provider Details

I. General information

NPI: 1689694788
Provider Name (Legal Business Name): MARK J. EDWARDS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 STATE HIGHWAY 7
SIDNEY NY
13838-2716
US

IV. Provider business mailing address

428 COUNTY HIGHWAY 1
MOUNT UPTON NY
13809-2103
US

V. Phone/Fax

Practice location:
  • Phone: 607-563-7333
  • Fax: 607-563-7333
Mailing address:
  • Phone: 607-563-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005949
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: