Provider Demographics
NPI:1700821774
Name:EDWARDS, CLYDE RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:RANDALL
Last Name:EDWARDS
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:P. O. BOX 162970
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-2970
Mailing Address - Country:US
Mailing Address - Phone:800-443-3672
Mailing Address - Fax:
Practice Address - Street 1:424 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2644
Practice Address - Country:US
Practice Address - Phone:770-748-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030054207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000399385GMedicaid
D39794Medicare UPIN
GA000399385GMedicaid