Provider Demographics
NPI:1962443887
Name:EDMUNDS, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:EDMUNDS
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 1:2724 MIDDLEBURG DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2437
Mailing Address - Country:US
Mailing Address - Phone:803-251-6602
Mailing Address - Fax:803-251-6605
Practice Address - Street 1:2724 MIDDLEBURG DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2437
Practice Address - Country:US
Practice Address - Phone:803-251-6602
Practice Address - Fax:803-251-6605
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22045208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC220451Medicaid
SCH33356Medicare UPIN
SC220451Medicaid