Healthcare Provider Details

I. General information

NPI: 1609489624
Provider Name (Legal Business Name): MASON G EDMUNDS OCPSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

IV. Provider business mailing address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

V. Phone/Fax

Practice location:
  • Phone: 330-797-0070
  • Fax:
Mailing address:
  • Phone: 330-797-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA.162173
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberOCPSA.161826
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: