Provider Demographics
NPI:1881631174
Name:HOOVEN, EDMUND W JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:W
Last Name:HOOVEN
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:BUD
Other - Middle Name:
Other - Last Name:HOOVEN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-0900
Practice Address - Fax:410-601-0901
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001399363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00236585OtherR/R MEDICARE PROVIDER #
MDCA8374OtherR/R MEDICARE GROUP #
MDS567G052Medicare PIN
MDP00236585OtherR/R MEDICARE PROVIDER #