Provider Demographics
NPI:1417977430
Name:EDELMAN, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:EDELMAN
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 1:710 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1941
Mailing Address - Country:US
Mailing Address - Phone:715-256-3000
Mailing Address - Fax:
Practice Address - Street 1:902 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1992
Practice Address - Country:US
Practice Address - Phone:715-258-1160
Practice Address - Fax:715-256-3079
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30386208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34265900Medicaid
WI002469010OtherMEDICARE PTAN
WI020052618OtherRAILROAD MEDICARE
WI34265900Medicaid