Provider Demographics
NPI:1902801897
Name:NOWICKI, EDMUND (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:NOWICKI
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 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:615-309-3338
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:STE 1
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:877-892-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6193A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113930400Medicaid
WY308483OtherBCBS
WYG64309Medicare UPIN
WY80163127Medicare PIN
WY308483OtherBCBS