Provider Demographics
NPI:1659340230
Name:EDMONDSON, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:EDMONDSON
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 1:1311 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4104
Mailing Address - Country:US
Mailing Address - Phone:410-961-5500
Mailing Address - Fax:800-600-4124
Practice Address - Street 1:1311 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4104
Practice Address - Country:US
Practice Address - Phone:410-961-5500
Practice Address - Fax:800-600-4124
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045766207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58597Medicare UPIN