Provider Demographics
NPI:1407242993
Name:ALLAN C EDSON, D.O., PC
Entity Type:Organization
Organization Name:ALLAN C EDSON, D.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-294-5224
Mailing Address - Street 1:425 MEDICAL DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4945
Mailing Address - Country:US
Mailing Address - Phone:801-294-5224
Mailing Address - Fax:801-294-5269
Practice Address - Street 1:425 MEDICAL DR
Practice Address - Street 2:SUITE 207
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4945
Practice Address - Country:US
Practice Address - Phone:801-294-5224
Practice Address - Fax:801-294-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3495321204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty