Provider Demographics
NPI:1720066038
Name:EDMONDS, PHILLIP C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:C
Last Name:EDMONDS
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 1:300 E MCBEE AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8602
Mailing Address - Fax:
Practice Address - Street 1:25 CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-297-7900
Practice Address - Fax:864-458-8841
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC238120Medicaid
SC238120Medicaid