Basic Information
| Provider Information | |||||||||
| NPI: | 1508934464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDMISTON | ||||||||
| FirstName: | BART | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 13TH ST | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285752902 | ||||||||
| FaxNumber: | 2285752917 | ||||||||
| Practice Location | |||||||||
| Address1: | 3631 BIENVILLE BLVD. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288189620 | ||||||||
| FaxNumber: | 2288189750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | EC-05-091 | ME | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 20298 | MS | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | 20298 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.