Basic Information
Provider Information | |||||||||
NPI: | 1508871070 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OBEID | ||||||||
FirstName: | EDMOND | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1605 N CEDAR CREST BLVD STE 110B | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181042351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109731410 | ||||||||
FaxNumber: | 6109731449 | ||||||||
Practice Location | |||||||||
Address1: | 1720 W. FAIRMOUNT ST | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 18104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108412798 | ||||||||
FaxNumber: | 6108412796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2006 | ||||||||
LastUpdateDate: | 05/02/2019 | ||||||||
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 | MD429693 | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 50062407 | 01 |   | CBC | OTHER | 1017873020001 | 05 | PA |   | MEDICAID | P008401 | 01 |   | GATEWAY | OTHER | 001902866 | 01 |   | HIGHMARK BLUE SHIELD | OTHER | 2769924000 | 01 |   | IBC | OTHER | 20056021 | 01 |   | AMERIHEALTH MERCY HEALTH | OTHER |