Individual
EDGAR WOLLAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1660 MULKEY RD, STE B, AUSTELL, GA 30106
(678) 460-2700
(770) 739-0212
Mailing address
1660 MULKEY RD, STE B, AUSTELL, GA 30106
(678) 460-2700
(770) 739-0212
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
19436
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0001416187H
—
GA
05
—
000146187B
—
GA
05
—
000146187C
—
GA
05
—
000146187D
—
GA
05
—
000146187E
—
GA
05
—
000146187F
—
GA
05
—
000146187G
—
GA
01
—
03169
BCBS GROUP #
GA
01
—
110059639
RR MEDICARE
GA
01
—
356860
BCBS
GA
01
—
581992673003
UHC
GA
01
—
920632
AETNA
GA
Enumeration date
07/06/2006
Last updated
10/19/2011
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