Provider Demographics
NPI:1285678953
Name:EDHOLM, THOMAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:EDHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:510-879-9120
Practice Address - Street 1:KONA COMMUNITY HOSPTIAL
Practice Address - Street 2:79-1019 HAUKAPILA STREET
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-7920
Practice Address - Country:US
Practice Address - Phone:808-547-9593
Practice Address - Fax:808-599-2714
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-07-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
HIMD 13810207PE0004X
CAG80869207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G45544Medicare UPIN