Provider Demographics
NPI:1548454051
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 1:3500 INTERSTATE 30 BLDG C
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2696
Mailing Address - Country:US
Mailing Address - Phone:972-682-1307
Mailing Address - Fax:972-686-2546
Practice Address - Street 1:3500 INTERSTATE 30 BLDG C
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2696
Practice Address - Country:US
Practice Address - Phone:972-682-1307
Practice Address - Fax:972-686-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2008-02-17
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
TX1208280014Medicare NSC