Provider Demographics
NPI:1568461002
Name:BOONE, EDGAR ALAN (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALAN
Last Name:BOONE
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:P.O.BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-5508
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027914E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104152OtherUPMC HEALTH PLAN
1427335181OtherCBQ
PA0010968930002Medicaid
PA0473267OtherAETNA
PA010028191OtherPALMETTO GBA RR MEDICARE
PA000067334OtherHIGHMARK
1427335140OtherWHITERIVER
PA1409575OtherUNITED MINE WORKERS
PA0010968930002Medicaid
PAB42233Medicare UPIN
030113Medicare Oscar/Certification