Provider Demographics
NPI:1578542296
Name:EDELSON, CHARLES W (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:EDELSON
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 1:53 SOUTH LAWN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522
Mailing Address - Country:US
Mailing Address - Phone:914-772-5773
Mailing Address - Fax:914-963-6426
Practice Address - Street 1:55 SOUTH LAWN AVENUE
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522
Practice Address - Country:US
Practice Address - Phone:914-772-5773
Practice Address - Fax:914-963-6426
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121222-1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY441202721OtherMEDICARE PTAN
NY00279676Medicaid
NY00279676Medicaid
B13277Medicare UPIN
CE03375810Medicare ID - Type Unspecified
NY0353020001Medicare NSC