Provider Demographics
NPI:1790074037
Name:EDDIN MEDICAL SERVICES
Entity Type:Organization
Organization Name:EDDIN MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-341-3366
Mailing Address - Street 1:PO BOX 291140
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-1140
Mailing Address - Country:US
Mailing Address - Phone:386-341-3366
Mailing Address - Fax:386-615-8208
Practice Address - Street 1:2123 S PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3005
Practice Address - Country:US
Practice Address - Phone:386-341-3366
Practice Address - Fax:386-615-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273953400Medicaid
FL273953400Medicaid