Provider Demographics
NPI:1306934443
Name:EDDIEPMD INC
Entity type:Organization
Organization Name:EDDIEPMD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-386-0909
Mailing Address - Street 1:840 S RANCHO DR
Mailing Address - Street 2:STE. #4-338
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3837
Mailing Address - Country:US
Mailing Address - Phone:702-386-0909
Mailing Address - Fax:702-386-0707
Practice Address - Street 1:601 S RANCHO DR
Practice Address - Street 2:STE A-6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4899
Practice Address - Country:US
Practice Address - Phone:702-386-0909
Practice Address - Fax:702-386-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36465Medicare PIN