1437204864 NPI number — MEDICAL EDGE HEALTHCARE GROUP PA

Table of content: (NPI 1437204864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437204864 NPI number — MEDICAL EDGE HEALTHCARE GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL EDGE HEALTHCARE GROUP PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437204864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9229 LYNDON B JOHNSON FWY
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-739-3637
Provider Business Mailing Address Fax Number:
972-739-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 W RALPH M HALL PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ROCKWALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75032-6658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-771-8686
Provider Business Practice Location Address Fax Number:
972-772-3424
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEIGHTEN
Authorized Official First Name:
CLAY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-739-3001

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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