Provider Demographics
NPI:1457307811
Name:EDEN, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:EDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-0298
Mailing Address - Country:US
Mailing Address - Phone:518-475-1515
Mailing Address - Fax:518-475-0645
Practice Address - Street 1:1220 NEW SCOTLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9208
Practice Address - Country:US
Practice Address - Phone:518-475-1515
Practice Address - Fax:518-475-0645
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239425174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02749113Medicaid