MEDICARE: JOSE EDGARDO GONZALEZ CRUZ IDHS

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	1710I1003X	Independent Duty Medical Technicians
2	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1588471106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE EDGARDO GONZALEZ CRUZ IDHS

Provider Business Mailing Address
First Line	:	5019 GREEN BLUFF CT
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-9327
Country	:	US
Telephone Number	:	787-478-1112
Fax Number	:

Provider Business Practice Location Address
First Line	:	5019 GREEN BLUFF CT
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-9327
Country	:	US
Telephone Number	:	787-478-1112
Fax Number	:

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

Provider Enumeration Date	:	12/17/2024
Last Update Date	:	12/17/2024

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