Provider Demographics
NPI:1821123654
Name:EDMUND BOULTING M.D. PA
Entity Type:Organization
Organization Name:EDMUND BOULTING M.D. PA
Other - Org Name:LAKE MARY OBSTETRICS AND GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:K
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-323-2727
Mailing Address - Street 1:2500 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3501
Mailing Address - Country:US
Mailing Address - Phone:407-323-2727
Mailing Address - Fax:407-323-2771
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-323-2727
Practice Address - Fax:407-323-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70127207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty