Provider Demographics
NPI:1679558720
Name:ST. MARY, EDWARD W (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:W
Last Name:ST. MARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5625
Mailing Address - Fax:
Practice Address - Street 1:205 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5625
Practice Address - Fax:321-728-8649
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53713207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013473400Medicaid
FL200037430OtherRR MEDICARE
FL07142OtherBCBS
FL048545400Medicaid
75520Medicare UPIN