Healthcare Provider Details

I. General information

NPI: 1467957829
Provider Name (Legal Business Name): ADAM DEAN EDWARDS CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD DEPT OF
SAINT LOUIS MO
63141
US

IV. Provider business mailing address

339 CONSORT DR
BALLWIN MO
63011-4439
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-9224
  • Fax: 636-386-7679
Mailing address:
  • Phone: 636-386-9224
  • Fax: 636-386-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2018016968
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number24570564
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number111
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number75000155A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: