=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679558720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD W ST. MARY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 03/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 E NASA BLVD
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-1950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-361-5625
-----------------------------------------------------
Fax | 321-728-8649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 S FISKE BLVD
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-361-5625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME53713
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------