Provider Demographics
NPI:1891862389
Name:EDWARDSON, PHILLIP L (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:EDWARDSON
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 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN193292084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN830593500OtherMEDICAL ASSISTANCE
MN1518064Medicare UPIN
MNHP13217Medicare UPIN
MN830593500OtherMEDICAL ASSISTANCE
MN101924Medicare UPIN