MEDICARE: EDWARD L CHILDERS 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	207Q00000X	Family Medicine Physician	A65376	NM

General Provider Information

NPI Number	:	1679567986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD L CHILDERS DO

Provider Business Mailing Address
First Line	:	3825 EUBANK BLVD NE
Second Line	:	STE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-3575
Country	:	US
Telephone Number	:	505-298-8020
Fax Number	:	505-292-5006

Provider Business Practice Location Address
First Line	:	3825 EUBANK BLVD NE
Second Line	:	STE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-3575
Country	:	US
Telephone Number	:	505-298-8020
Fax Number	:	505-292-5006

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	12/16/2010

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