1689873176 NPI number — B.O. EDWARDS, M.D., LLC

Table of content: (NPI 1689873176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689873176 NPI number — B.O. EDWARDS, M.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
B.O. EDWARDS, M.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689873176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 WOODLANDS RD
Provider Second Line Business Mailing Address:
PO BOX 110
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-769-7911
Provider Business Mailing Address Fax Number:
706-769-0826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 WOODLANDS RD
Provider Second Line Business Practice Location Address:
BOX 110
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677-1990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-769-7911
Provider Business Practice Location Address Fax Number:
706-769-0826
Provider Enumeration Date:
07/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
BUFORD
Authorized Official Middle Name:
OTTO
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
706-769-7911

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  028160 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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