MEDICARE: EDEMA PARTNERS, PLLC

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	261QP2000X	Physical Therapy Clinic/Center	001579	KY
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	332BC3200X	Customized Equipment (DME)
4	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000972249	OTHER	KY	ANTHEM BCBS

General Provider Information

NPI Number	:	1306214903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEMA PARTNERS, PLLC

Provider Business Mailing Address
First Line	:	1160 EASTERN PKWY STE 2313
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40217-1405
Country	:	US
Telephone Number	:	502-309-9800
Fax Number	:	502-309-9797

Provider Business Practice Location Address
First Line	:	1169 EASTERN PKWY
Second Line	:	SUITE 2313
City	:	LOUISVILLE
State	:	KY
Zip	:	40217-1417
Country	:	US
Telephone Number	:	502-309-9800
Fax Number	:	502-309-9797

Authorized Official
Title or Position	:	CEO
Name	:	MARY BETH EVANS
Credential	:
Telephone Number	:	502-309-9800

Provider Enumeration Date	:	09/13/2015
Last Update Date	:	09/30/2021

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