Provider Demographics
NPI:1144675828
Name:RE, EDWARD III (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:RE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:D
Other - Last Name:RE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2020 WALNUT ST
Mailing Address - Street 2:APT 11J
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:DIVISION OF SPORTS MEDICINE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:718-598-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT210381208000000X, 2080S0010X
PAMD4685332080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics