Provider Demographics
NPI:1528728136
Name:EDWARDS, GEORGE C (HIS)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3704
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:
Practice Address - Street 1:4121 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6565
Practice Address - Country:US
Practice Address - Phone:618-619-2934
Practice Address - Fax:618-619-2934
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3442237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist