Provider Demographics
NPI:1720026255
Name:EDMONDSON, MARSHALL GRAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:GRAY
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:POST OFFICE BOX 980
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-0980
Mailing Address - Country:US
Mailing Address - Phone:662-620-7102
Mailing Address - Fax:662-620-7106
Practice Address - Street 1:620 CROSSOVER ROAD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4944
Practice Address - Country:US
Practice Address - Phone:662-620-7102
Practice Address - Fax:662-620-7106
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS061832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014322Medicaid
AL009700310Medicaid
MS300020470OtherRAILROAD MEDICARE
MSB30999Medicare UPIN
AL009700310Medicaid
MS300020470OtherRAILROAD MEDICARE