Provider Demographics
NPI:1588732366
Name:EDMONDSON, HENRY L (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:L
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:L
Other - Last Name:EDMONDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:103 DOCTORS PARK
Mailing Address - Street 2:THE LAIRD CLINIC OF FAMILY MEDICINE
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:662-323-2515
Mailing Address - Fax:662-323-2557
Practice Address - Street 1:103 DOCTORS PARK
Practice Address - Street 2:THE LAIRD CLINIC OF FAMILY MEDICINE
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-323-2515
Practice Address - Fax:662-323-2557
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115170Medicaid
B30774Medicare UPIN
080000454Medicare ID - Type Unspecified