Provider Demographics
NPI:1699506345
Name:EDGAR, JOHN WILLIAM (ATC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:EDGAR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 BENEDICTINE CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3580
Mailing Address - Country:US
Mailing Address - Phone:618-910-0139
Mailing Address - Fax:
Practice Address - Street 1:703 E US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-2210
Practice Address - Country:US
Practice Address - Phone:618-667-8851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960010242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer