Provider Demographics
NPI:1356388557
Name:EDWARDS, TIMOTHY J (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
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 1:2321 WINNERS CIRCLE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1945
Mailing Address - Country:US
Mailing Address - Phone:573-334-8870
Mailing Address - Fax:
Practice Address - Street 1:1429 N MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:573-334-8870
Practice Address - Fax:573-388-2310
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006010967207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200980308Medicaid
MO200980308Medicaid