MEDICARE: EDWARD JOSEPH NEIDHARDT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	89267	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114089000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD JOSEPH NEIDHARDT MD

Provider Business Mailing Address
First Line	:	103 S SAINT FRANCIS DR
Second Line	:	SUITE C
City	:	SANTA FE
State	:	NM
Zip	:	87501-2458
Country	:	US
Telephone Number	:	505-988-5667
Fax Number	:	505-820-1632

Provider Business Practice Location Address
First Line	:	103 S SAINT FRANCIS DR
Second Line	:	SUITE C
City	:	SANTA FE
State	:	NM
Zip	:	87501-2458
Country	:	US
Telephone Number	:	505-988-5667
Fax Number	:	505-820-1632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	06/27/2013

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Directions to “ EDWARD JOSEPH NEIDHARDT MD” Practice Location

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