MEDICARE: MICHELLE A EDWARDS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	100063-875	WI
2	2084P0800X	Psychiatry Physician	4301508340	MI
3	390200000X	Student in an Organized Health Care Education/Training Program
4	2084P0800X	Psychiatry Physician	81341-20	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	82082	OTHER		AMERICAN BOARD OF PSYCHIATRY NEUROLOGY

General Provider Information

NPI Number	:	1730682386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE A EDWARDS MD

Provider Business Mailing Address
First Line	:	PO BOX 22040
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54305-2040
Country	:	US
Telephone Number	:	920-445-7210
Fax Number	:	920-445-7289

Provider Business Practice Location Address
First Line	:	310 E SAINT JOSEPH ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-2242
Country	:	US
Telephone Number	:	920-433-6073
Fax Number	:	920-431-0333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2018
Last Update Date	:	04/12/2023

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