Provider Demographics
NPI:1508821679
Name:PRINCE, EDWARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:2520 GREEN TECH DR
Practice Address - Street 2:STE D
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2300
Practice Address - Country:US
Practice Address - Phone:814-234-5021
Practice Address - Fax:814-235-3313
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD023847E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA154948Medicare ID - Type Unspecified
B40107Medicare UPIN