Provider Demographics
NPI:1225217763
Name:DAVID A. EDMONSON, M.D., PC
Entity Type:Organization
Organization Name:DAVID A. EDMONSON, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-641-6936
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-0194
Mailing Address - Country:US
Mailing Address - Phone:518-641-6936
Mailing Address - Fax:518-641-6939
Practice Address - Street 1:319 S MANNING BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1742
Practice Address - Country:US
Practice Address - Phone:518-641-6936
Practice Address - Fax:518-641-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236674-12086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02733833Medicaid
NY1750440699OtherINDIVIDUAL NPI #