Provider Demographics
NPI:1912908765
Name:MIEDEMA, EDWARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
Last Name:MIEDEMA
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 1:206 GAMBLE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-4439
Mailing Address - Country:US
Mailing Address - Phone:704-732-4409
Mailing Address - Fax:704-735-5784
Practice Address - Street 1:206 GAMBLE DR
Practice Address - Street 2:SUITE C
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4439
Practice Address - Country:US
Practice Address - Phone:704-732-4409
Practice Address - Fax:704-735-5784
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135MKMedicaid
NC2336611Medicare ID - Type Unspecified
NC89135MKMedicaid
NC5046770001Medicare NSC