MEDICARE: MR. CARL EDEN R-L.C.S.W.

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	1041C0700X	Clinical Social Worker	RO33051-1	NY

General Provider Information

NPI Number	:	1275835704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL EDEN R-L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 305
Second Line	:	VILLAGE STATION
City	:	NEW YORK
State	:	NY
Zip	:	10014-0305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3441 78TH ST
Second Line	:	1-I
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-2571
Country	:	US
Telephone Number	:	718-898-8918
Fax Number	:

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

Provider Enumeration Date	:	12/05/2010
Last Update Date	:	01/04/2011

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