Provider Demographics
NPI:1275748212
Name:EDGAR, RICKIE LLOYD (MD)
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:LLOYD
Last Name:EDGAR
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 1:1150 E SHERMAN BLVD STE 2400
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1886
Mailing Address - Country:US
Mailing Address - Phone:231-672-4243
Mailing Address - Fax:231-727-4214
Practice Address - Street 1:1150 E SHERMAN BLVD STE 2400
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1886
Practice Address - Country:US
Practice Address - Phone:231-672-4243
Practice Address - Fax:231-727-4214
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNONE207T00000X
FLME145997207T00000X
MI4301100714207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1763058OtherMEDICARE PTAN
MI1275748212Medicaid