Healthcare Provider Details

I. General information

NPI: 1063408300
Provider Name (Legal Business Name): BRYAN TODD EDWARDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19485 OLD JETTON RD SUITE 210
CORNELIUS NC
28031-6582
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-1830
  • Fax: 704-316-1835
Mailing address:
  • Phone: 704-316-1830
  • Fax: 704-316-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2006-00386
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: