Healthcare Provider Details

I. General information

NPI: 1285678953
Provider Name (Legal Business Name): THOMAS W EDHOLM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KONA COMMUNITY HOSPTIAL 79-1019 HAUKAPILA STREET
KEALAKEKUA HI
96750-7920
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 808-547-9593
  • Fax: 808-599-2714
Mailing address:
  • Phone: 510-851-7423
  • Fax: 510-879-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD 13810
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG80869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: