Provider Demographics
NPI:1447284724
Name:EDEN, MICHAEL W (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:EDEN
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 1:100 N EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1805
Mailing Address - Country:US
Mailing Address - Phone:859-258-5102
Mailing Address - Fax:859-258-5799
Practice Address - Street 1:100 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-258-5102
Practice Address - Fax:859-258-5799
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36000818OtherASC MEDICAID GROUP
KY37903705OtherMEDICAID LAB GROUP
KY64280852Medicaid
KY4000501OtherMEDICARE LAB NUMBER
KYASC1019OtherASC MEDICARE GROUP
KYCB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP
KYCB5773OtherRR MEDICARE GROUP
E89885Medicare UPIN