=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114082815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC RUSSELL EDELMAN P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2006
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 PARKINGWAY ST #2
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-5058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-328-1242
-----------------------------------------------------
Fax | 617-328-3386
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 POND ST
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-504-3358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT10385
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------