Provider Demographics
NPI:1831356559
Name:EDMONSON AESTHETIC FACIAL SURGERY LLC
Entity type:Organization
Organization Name:EDMONSON AESTHETIC FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROP
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER-EDMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-265-6344
Mailing Address - Street 1:910 ADAMS ST SE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3730
Mailing Address - Country:US
Mailing Address - Phone:256-265-6344
Mailing Address - Fax:256-265-7965
Practice Address - Street 1:910 ADAMS ST SE
Practice Address - Street 2:SUITE 130
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3730
Practice Address - Country:US
Practice Address - Phone:256-265-6344
Practice Address - Fax:256-265-7965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26946207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH81403Medicare UPIN