MEDICARE: DR. EDSON ERKULVRAWATR M.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	208VP0014X	Interventional Pain Medicine Physician	12262	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	104448	OTHER	NV	MEDICARE PTAN

General Provider Information

NPI Number	:	1306053848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDSON ERKULVRAWATR M.D.

Provider Business Mailing Address
First Line	:	6950 W DESERT INN RD
Second Line	:	STE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3171
Country	:	US
Telephone Number	:	702-259-5550
Fax Number	:	702-259-5554

Provider Business Practice Location Address
First Line	:	6950 W DESERT INN RD
Second Line	:	STE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3171
Country	:	US
Telephone Number	:	702-259-5550
Fax Number	:	702-259-5554

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	11/02/2007

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