Healthcare Provider Details

I. General information

NPI: 1902816549
Provider Name (Legal Business Name): WAYNE R. EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/31/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 HIGHWAY 645 SUITE 110
INEZ KY
41224
US

IV. Provider business mailing address

142 QUAIL WALK
PIKEVILLE KY
41501-1430
US

V. Phone/Fax

Practice location:
  • Phone: 606-534-4002
  • Fax: 606-534-4007
Mailing address:
  • Phone: 606-253-3045
  • Fax: 606-432-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number34226
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34226
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number34226
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number34226
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number34226
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: