Provider Demographics
NPI:1508934464
Name:EDMISTON, BART J SR (MD)
Entity Type:Individual
Prefix:DR
First Name:BART
Middle Name:J
Last Name:EDMISTON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:228-575-2902
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:3631 BIENVILLE BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-818-9620
Practice Address - Fax:228-818-9750
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEEC-05-091207L00000X
MS20298208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine