Provider Demographics
NPI:1023394707
Name:SAMUEL M EDWARDS M D P A
Entity Type:Organization
Organization Name:SAMUEL M EDWARDS M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TARNOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-736-7244
Mailing Address - Street 1:750 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-736-7244
Mailing Address - Fax:386-736-8538
Practice Address - Street 1:750 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-736-7244
Practice Address - Fax:386-736-8538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272821400Medicaid
FL25225Medicare PIN