Basic Information
| Provider Information | |||||||||
| NPI: | 1548237050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | HUNTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1947A MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370435066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316475034 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD06885 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300056942 | 01 | RAILROAD MEDICARE | OTHER | 3057437 | 01 | BCBS | OTHER | 3328417 | 05 | TN | MEDICAID | 4102528 | 01 | BCBS | OTHER | 300056942 | 01 | RR MEDICARE | OTHER | 3328418 | 05 | TN | MEDICAID |