Basic Information
| Provider Information | |||||||||
| NPI: | 1053341792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDENFIELD | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | PERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10335 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622409870 | ||||||||
| FaxNumber: | 2622409869 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 SUNSET BLVD | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037912000 | ||||||||
| FaxNumber: | 8037912660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20-18692 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 186925 | 05 | SC | MEDICAID |