Provider Demographics
NPI:1710527627
Name:EDGERSON, REGINALD M
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:M
Last Name:EDGERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:20600 CHAGRIN BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5334
Practice Address - Country:US
Practice Address - Phone:216-295-7239
Practice Address - Fax:216-295-7240
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty