Provider Demographics
NPI:1629064134
Name:EDELMAN, SAMUEL B (DO)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:EDELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS156632080P0203X
PAOS008325L207P00000X
GA0708042080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1168602Medicaid
GA003115568BMedicaid
AL154008Medicaid
202I375257Medicare Oscar/Certification
LAE94557Medicare UPIN
LA4F542Medicare ID - Type Unspecified