MEDICARE: DR. RANDALL L. EDWARDS

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	207W00000X	Ophthalmology Physician	466	SD

General Provider Information

NPI Number	:	1841445368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. RANDALL L. EDWARDS

Provider Business Mailing Address
First Line	:	1605 EGLIN ST STE 2
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6107
Country	:	US
Telephone Number	:	605-341-6000
Fax Number	:	605-341-6001

Provider Business Practice Location Address
First Line	:	1605 EGLIN ST
Second Line	:	STE. 2
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6107
Country	:	US
Telephone Number	:	605-341-6000
Fax Number	:	605-341-6001

Authorized Official
Title or Position	:	OPTOMETRIST/SELF
Name	:	DR. RANDALL L. EDWARDS
Credential	:	OD
Telephone Number	:	605-341-6000

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	12/02/2009

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