MEDICARE: DR. LAUREL D EDMUNDSON MD

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	207Q00000X	Family Medicine Physician	243316	NY

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	:	1518122993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAUREL D EDMUNDSON MD

Provider Business Mailing Address
First Line	:	17 MAIN ST
Second Line	:	SUITE 302
City	:	CORTLAND
State	:	NY
Zip	:	13045-6606
Country	:	US
Telephone Number	:	607-753-3797
Fax Number	:	607-753-6677

Provider Business Practice Location Address
First Line	:	228 PARK AVE S # 49409
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10003-1502
Country	:	US
Telephone Number	:	646-760-6669
Fax Number	:	646-213-2042

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

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	12/27/2024

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