=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851430177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL WAYNE EDGERLY PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3512 HIGHWAY 365
-----------------------------------------------------
City | NEDERLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77627-7834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-722-7116
-----------------------------------------------------
Fax | 409-722-7450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3512 HIGHWAY 365
-----------------------------------------------------
City | NEDERLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77627-7834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-722-7116
-----------------------------------------------------
Fax | 409-722-7450
-----------------------------------------------------
=====================================================
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 | 1072734
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------