MEDICARE: EDEN HEALTH MEDICAL PC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1407539059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN HEALTH MEDICAL PC

Provider Business Mailing Address
First Line	:	77 GOODELL ST STE 510
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14203-1258
Country	:	US
Telephone Number	:	917-261-4414
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 HUDSON YARDS FL 80
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-2170
Country	:	US
Telephone Number	:	917-261-4414
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DONALD WAYNE JENKINS
Credential	:
Telephone Number	:	917-261-4414

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	09/13/2024

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Directions to “EDEN HEALTH MEDICAL PC ” Practice Location

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