MEDICARE: ANTHONY EDWARDS

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	347C00000X	Private Vehicle	P6380361	GA
2	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1295534030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY EDWARDS

Provider Business Mailing Address
First Line	:	3050 LOST CABIN PL
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-8648
Country	:	US
Telephone Number	:	404-281-8406
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 LOST CABIN PL
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-8648
Country	:	US
Telephone Number	:	404-281-8406
Fax Number	:

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

Provider Enumeration Date	:	03/12/2025
Last Update Date	:	03/12/2025

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