Healthcare Provider Details

I. General information

NPI: 1770603565
Provider Name (Legal Business Name): G.P.EDWARDS M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

IV. Provider business mailing address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

V. Phone/Fax

Practice location:
  • Phone: 310-449-1188
  • Fax:
Mailing address:
  • Phone: 949-263-8620
  • Fax: 949-263-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE KEITH EDWARDS
Title or Position: OWNER
Credential: M.D.
Phone: 310-449-1188