MEDICARE: MRS. KIMBERLY ROSE EDWARDS PT, DPT

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	225100000X	Physical Therapist	5094	OK

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	:	1710135330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY ROSE EDWARDS PT, DPT

Provider Business Mailing Address
First Line	:	409 DAISY DR
Second Line	:	STE F-2
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-7410
Country	:	US
Telephone Number	:	918-458-9235
Fax Number	:	918-458-9236

Provider Business Practice Location Address
First Line	:	2234 W HOUSTON ST STE B
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-3519
Country	:	US
Telephone Number	:	918-259-1888
Fax Number	:	918-251-3725

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

Provider Enumeration Date	:	09/08/2008
Last Update Date	:	06/27/2016

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