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General NPI Number Information
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NPI Number | 1215131842
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Entity Type | Individual
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Provider Name | JEREMY ROBERT EDMISTON D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 08/29/2012
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Provider Practice Location Address
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Address Line | 4110 WARRENSVILLE CENTER RD
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City | BEACHWOOD
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State | OH
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Zip | 44122-7024
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Country | US
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Telephone | 216-491-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 1755 LOCKWOOD OVAL
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City | TWINSBURG
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State | OH
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Zip | 44087-2508
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Country | US
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Telephone | 216-410-1755
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 34.008886
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License Number State | OH
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