Provider Demographics
NPI:1992860985
Name:WHITNEY, EDWIN GLENN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:GLENN
Last Name:WHITNEY
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 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-838-8563
Practice Address - Street 1:157 CLINIC AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
Practice Address - Country:US
Practice Address - Phone:770-812-5902
Practice Address - Fax:770-812-5903
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0446042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000841079BMedicaid
GA000841079DMedicaid
GA000841079IMedicaid
GA000841079CMedicaid
GA000841079CMedicaid
GA000841079IMedicaid