MEDICARE: MR. EDGAR E CORDOBA JR. LMSW

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	MSW007376	GA

General Provider Information

NPI Number	:	1417433616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDGAR E CORDOBA JR. LMSW

Provider Business Mailing Address
First Line	:	22219 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-3227
Country	:	US
Telephone Number	:	850-424-1923
Fax Number	:

Provider Business Practice Location Address
First Line	:	22219 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-3227
Country	:	US
Telephone Number	:	850-424-1923
Fax Number	:

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

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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