Basic Information
| Provider Information | |||||||||
| NPI: | 1699850966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDLUND | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 SHOUP AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087346760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 228 SHOUP AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087346760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 01/26/2008 | ||||||||
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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 | 2084P0800X | E-3275 | AR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | M-10108 | ID | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.