Provider Demographics
NPI:1285762955
Name:EDEN MEDICAL CLINIC PA
Entity type:Organization
Organization Name:EDEN MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:FELDHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:325-869-6171
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837-0967
Mailing Address - Country:US
Mailing Address - Phone:325-869-6171
Mailing Address - Fax:325-869-8118
Practice Address - Street 1:506 EAKER
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:TX
Practice Address - Zip Code:76837-0967
Practice Address - Country:US
Practice Address - Phone:325-869-6171
Practice Address - Fax:325-869-8118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3791261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOH92EMedicare PIN