Healthcare Provider Details

I. General information

NPI: 1568468015
Provider Name (Legal Business Name): EDWIN L CARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E GRANT ST SUITE 211
MACOMB IL
61455-3368
US

IV. Provider business mailing address

515 E GRANT ST SUITE 211
MACOMB IL
61455-3368
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-3706
  • Fax:
Mailing address:
  • Phone: 309-833-3706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036060998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: