Basic Information
| Provider Information | |||||||||
| NPI: | 1992860985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITNEY | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | GLENN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708388563 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 CLINIC AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301174454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708125902 | ||||||||
| FaxNumber: | 7708125903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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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 | 2086S0129X | 044604 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000841079B | 05 | GA | MEDICAID | 000841079D | 05 | GA | MEDICAID | 000841079I | 05 | GA | MEDICAID | 000841079C | 05 | GA | MEDICAID |