Provider Demographics
NPI:1043317282
Name:EDELSON, PAUL FREDERIC (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:FREDERIC
Last Name:EDELSON
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 1:16622 159TH ST
Mailing Address - Street 2:STE 1A
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441
Mailing Address - Country:US
Mailing Address - Phone:815-588-3889
Mailing Address - Fax:
Practice Address - Street 1:16622 159TH ST
Practice Address - Street 2:STE 1A
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441
Practice Address - Country:US
Practice Address - Phone:815-588-3889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics