Provider Demographics
NPI:1528063716
Name:UNDERWOOD, EDGAR S (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:S
Last Name:UNDERWOOD
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:PO BOX 55309
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 19TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000082922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051536232OtherBLUE CROSS
AL051536233OtherBLUE CROSS
MS06479807Medicaid
AL009938902Medicaid
AL051536231OtherBLUE CROSS
AL051536231OtherBLUE CROSS
AL009938902Medicaid