MEDICARE: DR. MARY-ELLEN ADELE EDMISTON DO

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	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician	OS16990	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427477470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY-ELLEN ADELE EDMISTON DO

Provider Business Mailing Address
First Line	:	331 S FLORIDA AVE STE 201
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4626
Country	:	US
Telephone Number	:	863-329-2750
Fax Number	:

Provider Business Practice Location Address
First Line	:	331 S FLORIDA AVE STE 201
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-4626
Country	:	US
Telephone Number	:	863-329-2750
Fax Number	:

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

Provider Enumeration Date	:	04/07/2014
Last Update Date	:	05/05/2026

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