Active NPI
Jerrold C. Edelberg, PH.D.
- Clinical Psychologist
- South Portland, ME
National Provider Identifier
1619203973
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PS561
- Practice address
- 280B Gannett Dr
South Portland, ME 04106-6940 - Phone
- (207) 828-0048
- Fax
- (207) 772-3743
- NPI assigned
- Oct 21, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PS561 | ME | Primary |
Addresses
Primary practice location
280B Gannett Dr
South Portland, ME 04106-6940
Mailing address
280B Gannett Dr
South Portland, ME 04106-6940
Phone (207) 828-0048
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053467779 | Medicaid | ME |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PS561 | ME | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1256083200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1383696000000",
"number": "1619203973",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "280B GANNETT DR",
"city": "SOUTH PORTLAND",
"state": "ME",
"postal_code": "041066940",
"telephone_number": "207-828-0048",
"fax_number": "207-772-3743"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "280B GANNETT DR",
"city": "SOUTH PORTLAND",
"state": "ME",
"postal_code": "041066940",
"telephone_number": "207-828-0048",
"fax_number": "207-772-3743"
}
],
"practiceLocations": [],
"basic": {
"last_name": "EDELBERG",
"first_name": "JERROLD",
"middle_name": "C.",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-10-21",
"last_updated": "2013-11-06",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "ME",
"license": "PS561",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1053467779",
"state": "ME"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Portland, ME
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.