=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942253612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN KEITH NEWINGTON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6701 PAW PAW AVE
-----------------------------------------------------
City | COLOMA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49038-9519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-468-6430
-----------------------------------------------------
Fax | 269-468-0013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 AUSTIN DR
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49057-1180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-621-1345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5601001228
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------