Healthcare Provider Details

I. General information

NPI: 1427115690
Provider Name (Legal Business Name): HARRISON B EDGLEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5176 HILL RD E
LAKEPORT CA
95453-6300
US

IV. Provider business mailing address

PO BOX 951
GLENDALE CA
91209-0951
US

V. Phone/Fax

Practice location:
  • Phone: 888-453-6625
  • Fax: 818-550-0909
Mailing address:
  • Phone: 818-550-0900
  • Fax: 818-550-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA50453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: