Provider Demographics
NPI:1538125489
Name:EDWARDS, GEORGE KEITH (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:KEITH
Last Name:EDWARDS
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:PO BOX 48904
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-0904
Mailing Address - Country:US
Mailing Address - Phone:310-449-1188
Mailing Address - Fax:310-449-9136
Practice Address - Street 1:1328 22ND ST
Practice Address - Street 2:DEPARTMENT OF NUCLEAR MEDICINE
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2032
Practice Address - Country:US
Practice Address - Phone:310-829-8229
Practice Address - Fax:310-449-9136
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59625207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G596250Medicaid
CA00G596250OtherBLUE SHIELD
CAD90058Medicare UPIN
CA00G596250Medicaid
CAWG59625FMedicare PIN
CAWG59625DMedicare PIN
CA00G596250OtherBLUE SHIELD
CAWG59625HMedicare PIN