Provider Demographics
NPI:1114960887
Name:EDELEN, GEORGE ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROGER
Last Name:EDELEN
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 1:1653 E MCMURRAY BLVD STE 144
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5934
Mailing Address - Country:US
Mailing Address - Phone:520-836-8644
Mailing Address - Fax:520-836-2499
Practice Address - Street 1:1653 E MCMURRAY BLVD
Practice Address - Street 2:SUITE 144
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5934
Practice Address - Country:US
Practice Address - Phone:520-836-8644
Practice Address - Fax:520-836-2499
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30267207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ707698Medicaid
H23181Medicare UPIN
AZZ121831Medicare PIN