MEDICARE: TORIA ELYSE EDGE 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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	56631	KY

General Provider Information

NPI Number	:	1215490248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TORIA ELYSE EDGE MD

Provider Business Mailing Address
First Line	:	1780 NICHOLASVILLE RD STE 301
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1413
Country	:	US
Telephone Number	:	859-277-6636
Fax Number	:	859-277-1455

Provider Business Practice Location Address
First Line	:	1780 NICHOLASVILLE RD STE 301
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-1413
Country	:	US
Telephone Number	:	859-277-6636
Fax Number	:	859-277-1455

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

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	06/27/2022

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