Provider Demographics
NPI:1518242734
Name:EDSON MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:EDSON MEDICAL CLINIC, LLC
Other - Org Name:PCA PAIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-909-5866
Mailing Address - Street 1:16986 ROBBINS RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16986 ROBBINS RD
Practice Address - Street 2:SUITE 180
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2795
Practice Address - Country:US
Practice Address - Phone:800-909-9220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty