Provider Demographics
NPI:1891807434
Name:LAYNE, EDWARD AUGUSTUS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:AUGUSTUS
Last Name:LAYNE
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:PO BOX 77007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-1007
Mailing Address - Country:US
Mailing Address - Phone:404-681-0000
Mailing Address - Fax:404-365-8354
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 340
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-681-0000
Practice Address - Fax:404-365-8354
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021539207RG0100X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA021539OtherLICENSE
GA00204586BMedicaid
GA021539OtherLICENSE
GA10BBCDLMedicare ID - Type Unspecified