Basic Information
| Provider Information | |||||||||
| NPI: | 1154377109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILIPPE EDOUARD, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 4TH ST | ||||||||
| Address2: | #371 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954044057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073225679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1165 MONTGOMERY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075463210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | EDOUARD | ||||||||
| AuthorizedOfficialFirstName: | PHILIPPE | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7073225679 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | C51257 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00C512570 | 05 | CA | MEDICAID |