Provider Demographics
NPI:1255305546
Name:EDELSON, MITCHELL I (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:I
Last Name:EDELSON
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 1:3941 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1104
Mailing Address - Country:US
Mailing Address - Phone:215-481-4000
Mailing Address - Fax:215-576-0740
Practice Address - Street 1:3941 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1104
Practice Address - Country:US
Practice Address - Phone:215-481-4000
Practice Address - Fax:215-576-0740
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064402L207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG63883Medicare UPIN
PA005847Medicare ID - Type Unspecified