Healthcare Provider Details

I. General information

NPI: 1710126685
Provider Name (Legal Business Name): EDWARD SEDORY ATC, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2009
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24164 MONTEZUMA AVE THE BASIC SCHOOL - S3/ ATR
QUANTICO VA
22134-5123
US

IV. Provider business mailing address

3713 ALBERTA DR
FREDERICKSBURG VA
22408-7714
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-6558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB061117703
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000778
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: