=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952657447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD STANLEY NEMEC M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2012
-----------------------------------------------------
Last Update Date | 08/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4814 SEINE DR
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-467-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4814 SEINE DR
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 35044
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35044
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME79868
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------