Provider Demographics
NPI:1114346814
Name:MARK D EDEN MD PA
Entity Type:Organization
Organization Name:MARK D EDEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-997-9497
Mailing Address - Street 1:820 REUBEN ST STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4583
Mailing Address - Country:US
Mailing Address - Phone:830-997-9497
Mailing Address - Fax:830-997-5677
Practice Address - Street 1:820 REUBEN ST STE B
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4583
Practice Address - Country:US
Practice Address - Phone:830-997-9497
Practice Address - Fax:830-997-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133364304Medicaid
TXE10797Medicare UPIN
TX133364306Medicaid
TX00G11QOtherBCBSTX
TX00G11QMedicare PIN