Provider Demographics
NPI:1093430837
Name:EDEN TREE MEDICAL
Entity Type:Organization
Organization Name:EDEN TREE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, COO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:917-693-5738
Mailing Address - Street 1:107 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2466
Mailing Address - Country:US
Mailing Address - Phone:845-770-4686
Mailing Address - Fax:
Practice Address - Street 1:107 RIDGE RD
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2466
Practice Address - Country:US
Practice Address - Phone:845-770-4686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1598480337OtherNPI