Provider Demographics
NPI:1629064134
Name:EDELMAN, SAMUEL B (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:EDELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-660-6148
Mailing Address - Fax:706-660-2843
Practice Address - Street 1:710 CENTER STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-571-1220
Practice Address - Fax:706-571-1070
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15263R2080P0203X
LAMD.15263R2080P0203X
GA0708042080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1168602Medicaid
AL154008Medicaid
GA003115568BMedicaid
202I375257Medicare Oscar/Certification
LAE94557Medicare UPIN
LA4F542Medicare ID - Type Unspecified