Provider Demographics
NPI:1619573904
Name:EDWARDS MEDICAL PROVIDER GROUP
Entity Type:Organization
Organization Name:EDWARDS MEDICAL PROVIDER GROUP
Other - Org Name:EDWARDS MEDICAL PROVIDER GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-926-5846
Mailing Address - Street 1:2205 CORDILLERA WAY STE LL
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-6290
Mailing Address - Country:US
Mailing Address - Phone:800-829-4933
Mailing Address - Fax:
Practice Address - Street 1:2205 CORDILLERA WAY STE LL
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-6290
Practice Address - Country:US
Practice Address - Phone:970-693-0015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty