Healthcare Provider Details

I. General information

NPI: 1578597647
Provider Name (Legal Business Name): EDWARD HUNTER REDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E 1300 N
LOGAN UT
84341
US

IV. Provider business mailing address

655 E 1300 N
LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-792-6491
  • Fax:
Mailing address:
  • Phone: 435-792-6491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number180675
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number180675-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number180675-8905
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: