Healthcare Provider Details

I. General information

NPI: 1962443887
Provider Name (Legal Business Name): THOMAS B EDMUNDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 MIDDLEBURG DR
COLUMBIA SC
29204-2437
US

IV. Provider business mailing address

2724 MIDDLEBURG DR
COLUMBIA SC
29204-2437
US

V. Phone/Fax

Practice location:
  • Phone: 803-251-6602
  • Fax: 803-251-6605
Mailing address:
  • Phone: 803-251-6602
  • Fax: 803-251-6605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number22045
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: