=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558706713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD D MESSINA CRNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 N BROAD ST DEPARTMENT OF INTERVENTIONAL RADIOLOGY
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-0116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 N BROAD ST DEPARTMENT OF INTERVENTIONAL RADIOLOGY
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-0116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | SP012369
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------