Provider Demographics
NPI:1073539201
Name:OVERTON, EDGAR
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:OVERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1801
Practice Address - Country:US
Practice Address - Phone:800-822-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23904207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL128931Medicaid
AL051117103OtherBCBS
MO209297100Medicaid
AL051117094OtherBCBS
AL129009Medicaid
AL129011Medicaid
AL051117096OtherBCBS
MS06633521Medicaid
AL129007Medicaid
AL051117541OtherBCBS
AL129010Medicaid
AL051117095OtherBCBS
MS06633521Medicaid
AL129010Medicaid
IL$$$$$$$$$Medicaid
P00211578Medicare PIN
AL102I443174Medicare PIN
AL129011Medicaid