1639122021 NPI number — MEDICAL EDGE HEALTHCARE GROUP PA

Table of content: (NPI 1639122021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639122021 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:
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:
1639122021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2011
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 STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-4403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-739-3001
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9229 LYNDON B JOHNSON FWY STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-4403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-739-3001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

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: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 081500301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081500302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200384001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0046AZ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0099BH . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 186985102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081500315 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 081500316 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00516N . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 186985101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 186985103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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