Provider Demographics
NPI:1902828064
Name:EDWARDS, MICHAEL EARNEST (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EARNEST
Last Name:EDWARDS
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 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:SUITE G1
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4600
Mailing Address - Country:US
Mailing Address - Phone:662-841-7880
Mailing Address - Fax:662-821-1899
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE G1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-841-7880
Practice Address - Fax:662-821-1899
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS183822085R0202X
AL000122872085R0202X
TNMD00000195912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123835Medicaid
MS00123835Medicaid