Provider Demographics
NPI:1447255609
Name:EDGE MEDICAL CARE PC
Entity type:Organization
Organization Name:EDGE MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:EGO-OSUALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:301-434-9147
Mailing Address - Street 1:PO BOX 7909
Mailing Address - Street 2:
Mailing Address - City:LANGLEY PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20787-7909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5305 KENILWORTH AVE
Practice Address - Street 2:STE 100
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-3110
Practice Address - Country:US
Practice Address - Phone:301-277-7110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD 47156261QP2300X
DCMD 21355261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02849OtherMEDICARE GROUP PTAN
MD852000300Medicaid
MDG02849OtherMEDICARE GROUP PTAN
MD852000300Medicaid