Provider Demographics
NPI:1043464555
Name:MEDICAL EDGE HEALTHCARE GROUP PA
Entity type:Organization
Organization Name:MEDICAL EDGE HEALTHCARE GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIGHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-739-3001
Mailing Address - Street 1:891 KELLER PKWY STE 101A
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2486
Mailing Address - Country:US
Mailing Address - Phone:817-379-5100
Mailing Address - Fax:817-379-0479
Practice Address - Street 1:891 KELLER PKWY STE 101A
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2486
Practice Address - Country:US
Practice Address - Phone:817-379-5100
Practice Address - Fax:817-379-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1208280015Medicare NSC