Healthcare Provider Details

I. General information

NPI: 1609107846
Provider Name (Legal Business Name): JUSTIN R EDMONDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 SCHILLINGER RD S SUITE A
MOBILE AL
36695-4177
US

IV. Provider business mailing address

PO BOX 7627
MOBILE AL
36670-0627
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-0123
  • Fax: 251-633-0123
Mailing address:
  • Phone: 251-633-7211
  • Fax: 251-410-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.671
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: