Provider Demographics
NPI:1750331450
Name:WADSWORTH, EDIE (MD)
Entity Type:Individual
Prefix:
First Name:EDIE
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W MORRIS BLVD
Mailing Address - Street 2:HEALTHSTAR PHYSICIANS STE 400G
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:39813
Mailing Address - Country:US
Mailing Address - Phone:423-586-2410
Mailing Address - Fax:423-581-9692
Practice Address - Street 1:420 W MORRIS BLVD
Practice Address - Street 2:HEALTHSTAR PHYSICIANS STE 400G
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2283
Practice Address - Country:US
Practice Address - Phone:423-586-2410
Practice Address - Fax:423-581-9692
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD34074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3861633Medicaid
TN3861633Medicaid
H53142Medicare UPIN