Provider Demographics
NPI:1588760268
Name:EDERER, MICHAEL P (DO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:EDERER
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 1:1001 COLLEGE BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1049
Mailing Address - Country:US
Mailing Address - Phone:850-279-4417
Mailing Address - Fax:850-279-4212
Practice Address - Street 1:1001 COLLEGE BLVD W STE H
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1049
Practice Address - Country:US
Practice Address - Phone:850-279-4417
Practice Address - Fax:850-279-4212
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9533207LP2900X
ALPM 126, DO 136207LP2900X
ALDO 136207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-23910OtherBLUE CROSS
FLP00271270OtherRAILROAD MEDICARE
ALPO1328054OtherRAILROAD MEDICARE
FL16148OtherBLUE CROSS BLUE SHIELD
FL273858900Medicaid
AL511-61498OtherBC
FLK8216Medicare PIN
FLP00271270OtherRAILROAD MEDICARE
FL16148OtherBLUE CROSS BLUE SHIELD
AL102I053774Medicare Oscar/Certification
AL511-61498OtherBC
AL102I053774Medicare PIN