Provider Demographics
NPI:1952491524
Name:EDWARDS, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3465 N. PINES WAY
Mailing Address - Street 2:STE 104-118
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014
Mailing Address - Country:US
Mailing Address - Phone:307-699-0074
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:10207 GARLANREID PLACE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223
Practice Address - Country:US
Practice Address - Phone:307-699-0074
Practice Address - Fax:513-584-3020
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY223702086X0206X
OH35.091070208600000X, 2086X0206X
ARE-3646208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149591001Medicaid
OH2814011Medicaid
5M483Medicare PIN
C15425Medicare UPIN
OH2814011Medicaid