Provider Demographics
NPI:1528031077
Name:EDMONSON, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:EDMONSON
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 1:860 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4905
Mailing Address - Country:US
Mailing Address - Phone:662-377-7150
Mailing Address - Fax:662-377-7155
Practice Address - Street 1:860 SOUTH MADISON
Practice Address - Street 2:4TH FLOOR EAST TOWER
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-7150
Practice Address - Fax:662-377-7155
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16508207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00209211Medicaid
MS290000120Medicare ID - Type Unspecified
MS00209211Medicaid