Provider Demographics
NPI:1225058985
Name:MICHELSON, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:MICHELSON
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 1:440 RAYNOLDS ST # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-215-4600
Practice Address - Fax:915-545-7338
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-081159207P00000X
TXR2172207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00011027OtherRAILROAD MEDICARE
OH000000221111OtherUNISON
IN200052490AMedicaid
OH363840OtherWELLCARE MEDICAID
OHP00366728OtherMEDICARE RAILROAD
OH000000503561OtherANTHEM
OH2395886Medicaid
OH4480675OtherAETNA
OH744019OtherBUCKEYE MEDICAID
OHMI4104725Medicare PIN
OHMI4104724Medicare PIN
OH2395886Medicaid