Provider Demographics
NPI:1013922673
Name:EDWARDS, GARTH L (MD, DC)
Entity Type:Individual
Prefix:DR
First Name:GARTH
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:MD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22111 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1249
Mailing Address - Country:US
Mailing Address - Phone:708-748-5600
Mailing Address - Fax:708-748-5635
Practice Address - Street 1:22111 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1249
Practice Address - Country:US
Practice Address - Phone:708-748-5600
Practice Address - Fax:708-748-5635
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL723620OtherPTAN
IL1013922673OtherNPI
IL723620OtherPTAN