Basic Information
| Provider Information | |||||||||
| NPI: | 1992185292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDGINGTON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1545 W US HIGHWAY 30 | ||||||||
| Address2: | |||||||||
| City: | SCHERERVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463751562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197032440 | ||||||||
| FaxNumber: | 2197036751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 125066941 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 01085798A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000001543024 | 01 | IN | ANTHEM | OTHER | 300050201 | 05 | IN | MEDICAID |