Healthcare Provider Details

I. General information

NPI: 1740446483
Provider Name (Legal Business Name): EDWARD RANDOLPH HANDYSIDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 W HIGH ST
BRYAN OH
43506-1681
US

IV. Provider business mailing address

442 W HIGH ST
BRYAN OH
43506-1681
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-4517
  • Fax: 419-636-6438
Mailing address:
  • Phone: 419-636-4517
  • Fax: 419-636-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35095037
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: