Provider Demographics
NPI:1124588819
Name:EDMONDSON, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:EDMONDSON
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 1:4325 GREEN ROAD, COTTAGE 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4884
Mailing Address - Country:US
Mailing Address - Phone:330-467-7131
Mailing Address - Fax:216-591-0223
Practice Address - Street 1:4325 GREEN ROAD, COTTAGE 3
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-4884
Practice Address - Country:US
Practice Address - Phone:330-467-7131
Practice Address - Fax:216-591-0223
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW2488428Medicaid