Provider Demographics
NPI:1225009459
Name:DR. MARK J. EDMUNDS, DPM, P.L.L.C.
Entity Type:Organization
Organization Name:DR. MARK J. EDMUNDS, DPM, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:EDMUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:270-885-1203
Mailing Address - Street 1:1610 S MAIN ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1974
Mailing Address - Country:US
Mailing Address - Phone:270-885-1203
Mailing Address - Fax:270-885-1561
Practice Address - Street 1:1610 S MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1974
Practice Address - Country:US
Practice Address - Phone:270-885-1203
Practice Address - Fax:270-885-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00294213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8000049000Medicaid
DD3588OtherRAILROAD MEDICARE
KY9713Medicare PIN