1164429890 NPI number — STEVEN RAY EDMONDSON MD

Table of content: JONELLE GILLETTE (NPI 1487972352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164429890 NPI number — STEVEN RAY EDMONDSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMONDSON
Provider First Name:
STEVEN
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDMONDSON
Provider Other First Name:
STEVEN
Provider Other Middle Name:
RAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1164429890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3025 N TARRANT PKWY
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76177-8620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-431-1500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3025 N TARRANT PKWY
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76177-8620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-431-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  G8830 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: G8830 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207VX0000X , with the licence number: G8830 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 131769510 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83022Y . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131769508 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109380901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131769502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131769509 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0737147 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2357545 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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