Provider Demographics
NPI:1548237050
Name:WELLES, EDWARD HUNTER (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HUNTER
Last Name:WELLES
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 1:1947A MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5066
Mailing Address - Country:US
Mailing Address - Phone:931-647-5034
Mailing Address - Fax:931-552-6663
Practice Address - Street 1:620 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-660-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD068852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300056942OtherRAILROAD MEDICARE
3057437OtherBCBS
TN3328417Medicaid
4102528OtherBCBS
300056942OtherRR MEDICARE
TN3328418Medicaid
300056942OtherRAILROAD MEDICARE
3057437OtherBCBS
TN3328418Medicaid