1548454051 NPI number — MEDICAL EDGE HEALTHCARE GROUP, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548454051 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:
1548454051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 INTERSTATE 30 BLDG C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75150-2696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-682-1307
Provider Business Mailing Address Fax Number:
972-686-2546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 INTERSTATE 30 BLDG C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75150-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-682-1307
Provider Business Practice Location Address Fax Number:
972-686-2546
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

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

Provider Taxonomy Codes

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

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





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