Provider Demographics
NPI:1548431208
Name:EDGE, LISA REYNOLDS (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:REYNOLDS
Last Name:EDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:CAROL
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1759
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39663207P00000X, 208M00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64114119Medicaid
KY7100102130Medicaid
KY000000642826OtherANTHEM BCBS PROVIDER #
KY7655700OtherAETNA PROVIDER #
KY64114119Medicaid
KY0123203Medicare PIN
KY000000642826OtherANTHEM BCBS PROVIDER #
KYI39854Medicare UPIN