Healthcare Provider Details

I. General information

NPI: 1427205418
Provider Name (Legal Business Name): ANDRE EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

IV. Provider business mailing address

1900 SILVER CROSS BLVD
NEW LENOX IL
60451-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-300-7303
  • Fax:
Mailing address:
  • Phone: 815-300-7303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036122992
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036.122992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: