Provider Demographics
NPI:1174504302
Name:CARMACK, EDWIN BLOUNT (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:BLOUNT
Last Name:CARMACK
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 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:509-665-6065
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048684207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0225361OtherL&I
WA8945510OtherCRIME VICTIMS
WAP01292756OtherRR MEDICARE
WA315405OtherL&I POST 7/21/13
WA1174504302Medicaid
WA1174504302Medicaid