Healthcare Provider Details

I. General information

NPI: 1912908765
Provider Name (Legal Business Name): EDWARD B MIEDEMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 GAMBLE DR SUITE C
LINCOLNTON NC
28092-4439
US

IV. Provider business mailing address

206 GAMBLE DR SUITE C
LINCOLNTON NC
28092-4439
US

V. Phone/Fax

Practice location:
  • Phone: 704-732-4409
  • Fax: 704-735-5784
Mailing address:
  • Phone: 704-732-4409
  • Fax: 704-735-5784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: