Provider Demographics
NPI:1912285446
Name:NELSON, EDMOND COLLIN JR (MD)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:COLLIN
Last Name:NELSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-4186
Practice Address - Fax:573-860-6179
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23146207R00000X
ALMD.32419207R00000X
WVWV-SE-1846207R00000X
AZ65734207R00000X, 208M00000X
LA321099207R00000X, 208M00000X
GA79603208M00000X
MO2017027303208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine