Provider Demographics
NPI:1124149711
Name:EDWARDS AND SISAM LLC
Entity type:Organization
Organization Name:EDWARDS AND SISAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-344-4700
Mailing Address - Street 1:215 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1649
Mailing Address - Country:US
Mailing Address - Phone:585-344-4700
Mailing Address - Fax:585-345-4191
Practice Address - Street 1:215 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1649
Practice Address - Country:US
Practice Address - Phone:585-344-4700
Practice Address - Fax:585-345-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216110207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02147804Medicaid
NY105570CKOtherPREFERREDCARE
NY0298063OtherGHI
NY10600580OtherFIDELIS
NY00025117002OtherUNIVERA
NY000526067002OtherBCBSWNY
NY000526067002OtherBCBSWNY
NY10600580OtherFIDELIS