Basic Information
Provider Information | |||||||||
NPI: | 1144333428 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDWARDS | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 152 DRESDEN AVE | ||||||||
Address2: |   | ||||||||
City: | GARDINER | ||||||||
State: | ME | ||||||||
PostalCode: | 043452615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075826608 | ||||||||
FaxNumber: | 2075822258 | ||||||||
Practice Location | |||||||||
Address1: | 152 DRESDEN AVE | ||||||||
Address2: |   | ||||||||
City: | GARDINER | ||||||||
State: | ME | ||||||||
PostalCode: | 043452615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075826608 | ||||||||
FaxNumber: | 2075822258 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2006 | ||||||||
LastUpdateDate: | 10/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 239417 | MA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2255 | ME | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 204D00000X | 2255 | ME | N |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |   |
ID Information
ID | Type | State | Issuer | Description | 1144333428 | 05 | ME |   | MEDICAID | 1144333428 | 05 | MA |   | MEDICAID | 432681899 | 05 | ME |   | MEDICAID |