Provider Demographics
NPI:1275802746
Name:THOMAS L EDMONDSON MD PA
Entity Type:Organization
Organization Name:THOMAS L EDMONDSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:410-961-5500
Mailing Address - Street 1:1311 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4104
Mailing Address - Country:US
Mailing Address - Phone:410-961-5500
Mailing Address - Fax:800-600-4124
Practice Address - Street 1:1311 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4104
Practice Address - Country:US
Practice Address - Phone:410-961-5500
Practice Address - Fax:800-600-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45766207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1659340230OtherNPI
MDF58597Medicare UPIN