Provider Demographics
NPI:1316978166
Name:WOLLAM, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:WOLLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:WOLLAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1660 MULKEY RD
Mailing Address - Street 2:STE B
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:678-460-2700
Mailing Address - Fax:770-739-0212
Practice Address - Street 1:1660 MULKEY RD
Practice Address - Street 2:STE B
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:678-460-2700
Practice Address - Fax:770-739-0212
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19436207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000146187CMedicaid
GA920632OtherAETNA
GA000146187EMedicaid
GA0001416187HMedicaid
GA000146187FMedicaid
GA110059639OtherRR MEDICARE
GA000146187BMedicaid
GA000146187DMedicaid
GA356860OtherBCBS
GA581992673003OtherUHC
GA000146187GMedicaid
GA03169OtherBCBS GROUP #
GA000146187EMedicaid