MEDICARE: NELSON GREY EDWARDS O.D.

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	152W00000X	Optometrist	4901003131	MI

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

General Provider Information

NPI Number	:	1194804583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELSON GREY EDWARDS O.D.

Provider Business Mailing Address
First Line	:	136 E GRAND RIVER AVE
Second Line	:	PO BOX 618
City	:	FOWLERVILLE
State	:	MI
Zip	:	48836-5136
Country	:	US
Telephone Number	:	517-223-9988
Fax Number	:	517-223-9071

Provider Business Practice Location Address
First Line	:	136 E GRAND RIVER AVE
Second Line	:
City	:	FOWLERVILLE
State	:	MI
Zip	:	48836-5136
Country	:	US
Telephone Number	:	517-223-9988
Fax Number	:	517-223-9071

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

Provider Enumeration Date	:	11/04/2006
Last Update Date	:	10/07/2009

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