Provider Demographics
NPI:1063599454
Name:EDMUND C LANDRY M D P C
Entity type:Organization
Organization Name:EDMUND C LANDRY M D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:C
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-888-2831
Mailing Address - Street 1:402 RECOVERY RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3235
Mailing Address - Country:US
Mailing Address - Phone:573-888-2831
Mailing Address - Fax:573-888-5408
Practice Address - Street 1:402 RECOVERY RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3235
Practice Address - Country:US
Practice Address - Phone:573-888-2831
Practice Address - Fax:573-888-5408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000146363207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO125262OtherANTHEM BC OF MISSOURI
MO98523OtherAR BLUE CROSS
MO425643OtherHEALTHLINK
MO=========OtherTRICARE
MO98523OtherAR BLUE CROSS
MO125262OtherANTHEM BC OF MISSOURI