MEDICARE: DR. EDSON ALEXIS 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

General Provider Information

NPI Number	:	1215686043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDSON ALEXIS MD

Provider Business Mailing Address
First Line	:	677 CHURCH ST NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1101
Country	:	US
Telephone Number	:	470-267-0620
Fax Number	:	770-999-2746

Provider Business Practice Location Address
First Line	:	677 CHURCH STREET ATTN: GME
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060
Country	:	US
Telephone Number	:	347-235-9817
Fax Number	:

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

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/02/2026

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