Basic Information
| Provider Information | |||||||||
| NPI: | 1700827920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVY | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | GILBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1814 | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433071814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837847 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433011814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837000 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35031752D | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000141633 | 01 | ANTHEM | OTHER | 0511137 | 05 | OH | MEDICAID | 0527468 | 01 | PALMETTO MEDICARE | OTHER | 311098079249 | 01 | MEDICAL MUTUAL | OTHER | 353079 | 01 | SUBMITTER NO. | OTHER | 341893458005 | 01 | MEDICAL MUTUAL | OTHER | 4486261 | 01 | AETNA | OTHER | 1601314 | 01 | UHC | OTHER | 0527463 | 01 | PALMETTO MEDICARE | OTHER |