Healthcare Provider Details

I. General information

NPI: 1679745590
Provider Name (Legal Business Name): WILLIAM THOMAS EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS ROAD
BOISE ID
83706
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2121
  • Fax: 505-820-5408
Mailing address:
  • Phone: 208-367-5171
  • Fax: 505-820-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD2010-0534
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberM-12213
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036.129296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: