Healthcare Provider Details

I. General information

NPI: 1073554275
Provider Name (Legal Business Name): EDWIN P HARMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

PO BOX 24146
JACKSON MS
39225-4146
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-6805
  • Fax: 601-926-4978
Mailing address:
  • Phone: 601-925-6723
  • Fax: 601-926-4978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4774
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number06918
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: