Provider Demographics
NPI:1659312742
Name:EVERTON A EDMONDSON MD PA
Entity Type:Organization
Organization Name:EVERTON A EDMONDSON MD PA
Other - Org Name:INTERVENTIONAL NEUROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EVERTON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:713-797-1180
Mailing Address - Street 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 1234
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-797-1180
Mailing Address - Fax:713-797-0641
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 1234
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-797-1180
Practice Address - Fax:713-797-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG94512084N0400X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190246201Medicaid
TX8AJ445OtherBLUE CROSS
TXB80300Medicare UPIN
TX6618980001Medicare NSC
TX190246201Medicaid