=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427191790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD J WREN III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 08/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 ANDRE ST SUITE 300
-----------------------------------------------------
City | NEW IBERIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70563-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-364-9225
-----------------------------------------------------
Fax | 337-364-6094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20452 YPS-CRED
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220-0452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-442-2406
-----------------------------------------------------
Fax | 614-442-2410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 015754
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------