Provider Demographics
NPI:1144212259
Name:EDLUND, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:EDLUND
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 320
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1733
Practice Address - Country:US
Practice Address - Phone:260-266-5300
Practice Address - Fax:260-266-5314
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029093A207PE0005X, 2083P0011X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0437807Medicaid
IN000000595625OtherANTHEM
IN000000614694OtherANTHEM
IN020037714OtherRR MEDICARE
IN1000095950AMedicaid
IN280001010OtherRR MEDICARE
IN100095950Medicaid
IN020037714Medicare PIN
IN000000595625OtherANTHEM
IN020037714OtherRR MEDICARE