Provider Demographics
NPI:1073554275
Name:HARMON, EDWIN P (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:P
Last Name:HARMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24146
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-925-6723
Mailing Address - Fax:601-926-4978
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-925-6805
Practice Address - Fax:601-926-4978
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4774207Q00000X
MS069182088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4774Medicaid
MS00017183Medicaid
MS302I345603Medicare PIN
MS00017183Medicaid
MS512I340004Medicare PIN
AK8EZ06RMedicare ID - Type Unspecified
AKMD4774Medicaid