MEDICARE: STEVEN R. EDMONDSON MD, PA

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	207V00000X	Obstetrics & Gynecology Physician	G8830	TX

General Provider Information

NPI Number	:	1164895355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN R. EDMONDSON MD, PA

Provider Business Mailing Address
First Line	:	3025 N TARRANT PKWY STE 240
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8620
Country	:	US
Telephone Number	:	817-431-1500
Fax Number	:	817-431-8193

Provider Business Practice Location Address
First Line	:	3025 N TARRANT PKWY STE 240
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8620
Country	:	US
Telephone Number	:	817-431-1500
Fax Number	:	817-431-8193

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. STEVEN RAY EDMONDSON
Credential	:	MD
Telephone Number	:	817-431-1500

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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