Provider Demographics
NPI:1063620722
Name:EDELEN, CONNIE (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:EDELEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4266 SUNBEAM RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2425
Mailing Address - Country:US
Mailing Address - Phone:904-407-7700
Mailing Address - Fax:904-407-6001
Practice Address - Street 1:4266 SUNBEAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2425
Practice Address - Country:US
Practice Address - Phone:904-407-7700
Practice Address - Fax:904-407-6001
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00028207QH0002X
VA0116018187390200000X
FLME134775207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916822Medicaid
NC1063620722Medicaid
SCNC1249Medicaid
NC5916822Medicaid
SCNC1249Medicaid
NCNC5080AMedicare PIN
NC2076941Medicare PIN
NCNC5080BMedicare PIN