Healthcare Provider Details

I. General information

NPI: 1598766255
Provider Name (Legal Business Name): JOSEPH GORDON EDELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W MITCHELL ST STE M40
PETOSKEY MI
49770-2278
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-3637
  • Fax: 231-487-6513
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number51996
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number29735
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2018-0675
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301114320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: