Provider Demographics
NPI:1508818691
Name:EDGEWATER GYNECOLOGY P A
Entity Type:Organization
Organization Name:EDGEWATER GYNECOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:METCHICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-427-4544
Mailing Address - Street 1:109 W. KNAPP AVENUE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132
Mailing Address - Country:US
Mailing Address - Phone:386-427-4544
Mailing Address - Fax:386-427-8688
Practice Address - Street 1:109 W. KNAPP AVENUE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132
Practice Address - Country:US
Practice Address - Phone:386-427-4544
Practice Address - Fax:386-427-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6156Medicare ID - Type Unspecified