Provider Demographics
NPI:1215131842
Name:EDMISTON, JEREMY ROBERT (DO)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROBERT
Last Name:EDMISTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 LOCKWOOD OVAL
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-2508
Mailing Address - Country:US
Mailing Address - Phone:216-410-1755
Mailing Address - Fax:
Practice Address - Street 1:4110 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7024
Practice Address - Country:US
Practice Address - Phone:216-491-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008886207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine