1639147283 NPI number — BRIAN R EDWARDS DO

Table of content: BRIAN R EDWARDS DO (NPI 1639147283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639147283 NPI number — BRIAN R EDWARDS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
BRIAN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639147283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 KUHNE RD
Provider Second Line Business Mailing Address:
CAPITAL REGION MEDICAL CLINIC OWENSVILLE
Provider Business Mailing Address City Name:
OWENSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-437-4168
Provider Business Mailing Address Fax Number:
573-437-4242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3536 KUHNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-437-4168
Provider Business Practice Location Address Fax Number:
573-437-4168
Provider Enumeration Date:
03/09/2006

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: 207Q00000X , with the licence number:  2003002799 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 208842808 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189703 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 440546366 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00189427 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2226070 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8129934001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: I13420 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 661032 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".




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