=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023394707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL M EDWARDS M D P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2011
-----------------------------------------------------
Last Update Date | 10/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-7244
-----------------------------------------------------
Fax | 386-736-8538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-7244
-----------------------------------------------------
Fax | 386-736-8538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. LYNETTE A TARNOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-736-7244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME0066309
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------