Provider Demographics
NPI:1861987521
Name:EDMUNDS, MIRANDA LYN (MD)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:LYN
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:MSC 8208-0016-01
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-2527
Mailing Address - Fax:314-747-8880
Practice Address - Street 1:1 CHILDREN'S PLACE MSC 8208-0016-01
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-454-2527
Practice Address - Fax:314-747-8880
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029589208000000X, 208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200061855Medicaid