Provider Demographics
NPI: | 1346287554 |
---|---|
Name: | ADAMS, EDWARD L (MD) |
Entity type: | Individual |
Prefix: | |
First Name: | EDWARD |
Middle Name: | L |
Last Name: | ADAMS |
Suffix: | |
Gender: | M |
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: | 3035 DEMERS AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | GRAND FORKS |
Mailing Address - State: | ND |
Mailing Address - Zip Code: | 58201-4018 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 701-746-7521 |
Mailing Address - Fax: | 701-795-2553 |
Practice Address - Street 1: | 3035 DEMERS AVE |
Practice Address - Street 2: | |
Practice Address - City: | GRAND FORKS |
Practice Address - State: | ND |
Practice Address - Zip Code: | 58201-4018 |
Practice Address - Country: | US |
Practice Address - Phone: | 701-746-7521 |
Practice Address - Fax: | 701-795-2553 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-31 |
Last Update Date: | 2007-12-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ND | ADA-23242 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 624K9AD | Other | BCBS |
ND | A011 | Other | TRICARE |
ND | 26734 | Other | BCBS |
ND | P00324744 | Other | RR MEDICARE |
ND | 10012 | Medicaid | |
ND | 10012 | Medicaid | |
ND | 5613280001 | Medicare NSC | |
ND | 711946 | Medicare PIN | |
ND | P00324744 | Other | RR MEDICARE |