MEDICARE: EDGAR MAEYENS MD

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	207ND0101X	MOHS-Micrographic Surgery Physician	MD08528	OR

General Provider Information

NPI Number	:	1871574947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDGAR MAEYENS MD

Provider Business Mailing Address
First Line	:	1793 13TH ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-2541
Country	:	US
Telephone Number	:	503-362-8385
Fax Number	:	503-362-8435

Provider Business Practice Location Address
First Line	:	375 PARK AVE
Second Line	:	SUITE 5
City	:	COOS BAY
State	:	OR
Zip	:	97420-2242
Country	:	US
Telephone Number	:	541-267-7543
Fax Number	:	541-267-2076

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	12/05/2017

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