Provider Demographics
NPI:1124580188
Name:EDP OF PENNSYLVANIA, PC
Entity Type:Organization
Organization Name:EDP OF PENNSYLVANIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-951-9644
Mailing Address - Street 1:7546 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-7528
Mailing Address - Country:US
Mailing Address - Phone:312-800-1270
Mailing Address - Fax:
Practice Address - Street 1:7546 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-7528
Practice Address - Country:US
Practice Address - Phone:800-312-1279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDP OF PENNSYLVANIA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental