Provider Demographics
NPI:1689825838
Name:EDGEMONT PEDIATRICS, P.C
Entity Type:Organization
Organization Name:EDGEMONT PEDIATRICS, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:O
Authorized Official - Last Name:OGBEVOEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-398-6601
Mailing Address - Street 1:8710 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-2048
Mailing Address - Country:US
Mailing Address - Phone:618-398-6601
Mailing Address - Fax:618-398-4525
Practice Address - Street 1:8710 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-2048
Practice Address - Country:US
Practice Address - Phone:618-398-6601
Practice Address - Fax:618-398-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085372208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085372Medicaid
ILG55046Medicare UPIN