MEDICARE: EDWARD SEDORY ATC, EMT

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	146N00000X	Basic Emergency Medical Technician	B061117703	VA
2	2255A2300X	Athletic Trainer	0126000778	VA

General Provider Information

NPI Number	:	1710126685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD SEDORY ATC, EMT

Provider Business Mailing Address
First Line	:	3713 ALBERTA DR
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-7714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24164 MONTEZUMA AVE
Second Line	:	THE BASIC SCHOOL - S3/ ATR
City	:	QUANTICO
State	:	VA
Zip	:	22134-5123
Country	:	US
Telephone Number	:	703-784-6558
Fax Number	:

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

Provider Enumeration Date	:	02/16/2009
Last Update Date	:	02/16/2009

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