Provider Demographics
NPI:1376783811
Name:P. EDWARDS CONRAD MD. P.C.
Entity Type:Organization
Organization Name:P. EDWARDS CONRAD MD. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS-CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-244-1192
Mailing Address - Street 1:3338 L COUNTRY CLUB RD PMB 112
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7425
Mailing Address - Country:US
Mailing Address - Phone:229-244-1192
Mailing Address - Fax:
Practice Address - Street 1:2935 N ASHLEY ST STE D-116
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1788
Practice Address - Country:US
Practice Address - Phone:229-244-1192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA452052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty