Healthcare Provider Details

I. General information

NPI: 1538125489
Provider Name (Legal Business Name): GEORGE KEITH EDWARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 22ND ST DEPARTMENT OF NUCLEAR MEDICINE
SANTA MONICA CA
90404-2032
US

IV. Provider business mailing address

PO BOX 48904
LOS ANGELES CA
90048-0904
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8229
  • Fax: 310-449-9136
Mailing address:
  • Phone: 310-449-1188
  • Fax: 310-449-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberG59625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: