Provider Demographics
NPI:1265806319
Name:EDWIN K HOUSE, MD
Entity type:Organization
Organization Name:EDWIN K HOUSE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:KEENAN
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-796-9241
Mailing Address - Street 1:22163 CROOM RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-4852
Mailing Address - Country:US
Mailing Address - Phone:352-796-9241
Mailing Address - Fax:
Practice Address - Street 1:22163 CROOM RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-4852
Practice Address - Country:US
Practice Address - Phone:352-796-9241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME9793291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53423Medicare UPIN