Healthcare Provider Details

I. General information

NPI: 1518242734
Provider Name (Legal Business Name): EDSON MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16986 ROBBINS RD SUITE 180
GRAND HAVEN MI
49417-2795
US

IV. Provider business mailing address

16986 ROBBINS RD SUITE 180
GRAND HAVEN MI
49417-2795
US

V. Phone/Fax

Practice location:
  • Phone: 800-909-9220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM EDSON
Title or Position: PRESIDENT
Credential:
Phone: 800-909-5866