Provider Demographics
NPI:1568467447
Name:NUNNERY, EDWIN W JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:W
Last Name:NUNNERY
Suffix:JR
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 1:2800 KEAGY ROAD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:770-736-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023649207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22BDCSHMedicare PIN
GAE99243Medicare UPIN