Provider Demographics
NPI:1275773954
Name:EDEN INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:EDEN INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT CERTIFIED
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RAYMER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:336-627-4896
Mailing Address - Street 1:405 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5045
Mailing Address - Country:US
Mailing Address - Phone:336-627-4896
Mailing Address - Fax:336-627-0139
Practice Address - Street 1:405 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5045
Practice Address - Country:US
Practice Address - Phone:336-627-4896
Practice Address - Fax:336-627-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty