Provider Demographics
NPI:1790866655
Name:BYNUM, T EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:EDWARD
Last Name:BYNUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TURNER
Other - Middle Name:EDWARD
Other - Last Name:BYNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01752
Mailing Address - Country:US
Mailing Address - Phone:508-624-0605
Mailing Address - Fax:508-229-8694
Practice Address - Street 1:65 FREMONT ST
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:MA
Practice Address - Zip Code:01752
Practice Address - Country:US
Practice Address - Phone:508-624-0605
Practice Address - Fax:508-229-8694
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44316207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2070235Medicaid
A67076Medicare UPIN
28758Medicare ID - Type Unspecified