Provider Demographics
NPI:1972586253
Name:EDWARDS, CHARMAINE E (MD)
Entity Type:Individual
Prefix:MRS
First Name:CHARMAINE
Middle Name:E
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278
Mailing Address - Country:US
Mailing Address - Phone:618-282-3831
Mailing Address - Fax:618-282-5476
Practice Address - Street 1:325 SPRING STREET
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278
Practice Address - Country:US
Practice Address - Phone:618-282-3831
Practice Address - Fax:618-282-5476
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106745207RG0100X
MO113266207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203825146Medicaid
MOG67025Medicare UPIN
MO0013548Medicare ID - Type Unspecified