Provider Demographics
NPI:1164620456
Name:EDWARDSON, JILL (MD, MPH)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:EDWARDSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 EASTERN AVE
Mailing Address - Street 2:A BUILDING, ROOM 121
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2735
Mailing Address - Country:US
Mailing Address - Phone:410-550-0335
Mailing Address - Fax:410-550-7840
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:A BUILDING, ROOM 121
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0335
Practice Address - Fax:410-550-7840
Is Sole Proprietor?:No
Enumeration Date:2007-07-07
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22095207V00000X
MDD72742207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD046490200Medicaid
MD225933Y86Medicare PIN