Provider Demographics
NPI:1902194434
Name:EDMUNDSON, SHEREDRICK ANTHONY
Entity Type:Individual
Prefix:MR
First Name:SHEREDRICK
Middle Name:ANTHONY
Last Name:EDMUNDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4233 SHAGBARK TRL
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-7311
Mailing Address - Country:US
Mailing Address - Phone:615-578-2541
Mailing Address - Fax:615-280-1160
Practice Address - Street 1:4233 SHAGBARK TRL
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-7311
Practice Address - Country:US
Practice Address - Phone:615-578-2541
Practice Address - Fax:615-280-1160
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00017384171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00017384Medicare UPIN