Basic Information
| Provider Information | |||||||||
| NPI: | 1215916234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 ACORN DR | ||||||||
| Address2: | |||||||||
| City: | GOFFSTOWN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030452942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3025988359 | ||||||||
| FaxNumber: | 6036636645 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MCGREGOR ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031023730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036636478 | ||||||||
| FaxNumber: | 6036636645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | C10006234 | DE | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 13663 | NH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001111901 | 05 | DE | MEDICAID | 30208364 | 05 | NH | MEDICAID | 1215916234 | 01 | NH | ANTHEM BCBS NH | OTHER | 1215916234 | 01 | NH | TRICARE | OTHER |