1679649636 NPI number — MEDICAL EDGE HEALTHCARE GROUP PA

Table of content: (NPI 1679649636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679649636 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:
1679649636
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:
972-739-3097
Provider Business Mailing Address Fax Number:
972-739-2673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7200 STATE HIGHWAY 161
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75039-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-506-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

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: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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