=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366736159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA KENNETH EDGERTON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2011
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6701 AIRPORT BLVD STE A208
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-266-3544
-----------------------------------------------------
Fax | 251-266-3543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 36258
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-1204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-318-2678
-----------------------------------------------------
Fax | 251-405-9900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2016-01821
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD.49740
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------