=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861661266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS MICHAEL EDWARDS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2008
-----------------------------------------------------
Last Update Date | 02/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N MAIN ST
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14569-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-535-0051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2636 CLINTON STREET RD
-----------------------------------------------------
City | ATTICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14011-9728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 595-591-0852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 002004-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------