Provider Demographics
NPI:1306214903
Name:EDEMA PARTNERS, PLLC
Entity Type:Organization
Organization Name:EDEMA PARTNERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-309-9800
Mailing Address - Street 1:1160 EASTERN PKWY STE 2313
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1405
Mailing Address - Country:US
Mailing Address - Phone:502-309-9800
Mailing Address - Fax:502-309-9797
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:SUITE 2313
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-309-9800
Practice Address - Fax:502-309-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-13
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 332B00000X, 332BC3200X
KY001579261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000972249OtherANTHEM BCBS
KY7100374170 (PT)Medicaid
KY7100377610 (OT)Medicaid
KYK196530Medicare PIN