Provider Demographics
NPI:1033630496
Name:EDEH, TONY A
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:A
Last Name:EDEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BOULDER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5534
Mailing Address - Country:US
Mailing Address - Phone:630-300-4202
Mailing Address - Fax:630-759-8636
Practice Address - Street 1:7 BOULDER RIDGE CT
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5534
Practice Address - Country:US
Practice Address - Phone:630-300-4202
Practice Address - Fax:630-759-8636
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver