Provider Demographics
NPI:1871532283
Name:GWIN, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:GWIN
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 1:1342 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4279
Mailing Address - Country:US
Mailing Address - Phone:417-886-2747
Mailing Address - Fax:417-886-2774
Practice Address - Street 1:1342 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4279
Practice Address - Country:US
Practice Address - Phone:417-886-2747
Practice Address - Fax:417-886-2774
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5222207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
107065OtherBLUE CROSS/BLUE SHIELD
MO200404507Medicaid
MO200404507Medicaid
107065OtherBLUE CROSS/BLUE SHIELD