1124010954 NPI number — DR. EDWARD J. WALSH M.D.

Table of content: (NPI 1306075189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124010954 NPI number — DR. EDWARD J. WALSH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
EDWARD
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124010954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 MERCY DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44708-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-489-1278
Provider Business Mailing Address Fax Number:
330-430-2778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 MERCY DR NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44708-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-489-1278
Provider Business Practice Location Address Fax Number:
330-430-2778
Provider Enumeration Date:
08/18/2005

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: 2085R0001X , with the licence number:  35059023 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000529637 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000224357 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2026695 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2326673 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 364106 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00445898 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 732806 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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