Provider Demographics
NPI:1841213790
Name:WYSONG, EDWARD DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DALE
Last Name:WYSONG
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 1:229 ATHENS ST
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-1854
Mailing Address - Country:US
Mailing Address - Phone:706-376-3957
Mailing Address - Fax:706-376-1356
Practice Address - Street 1:229 ATHENS ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1854
Practice Address - Country:US
Practice Address - Phone:706-376-3957
Practice Address - Fax:706-376-1356
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000090703AMedicaid
GA024242OtherBLUE CROSS
GACB5824OtherRAILROAD MEDICARE
GA000090703AMedicaid