Healthcare Provider Details

I. General information

NPI: 1730530502
Provider Name (Legal Business Name): DR. KENT RUSSELL EDWARDS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MULBERRY ST SW STE 202
LENOIR NC
28645-5463
US

IV. Provider business mailing address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 828-757-6464
  • Fax: 828-757-6424
Mailing address:
  • Phone: 843-792-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberLL39777
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2020-04205
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: