Provider Demographics
NPI:1003899766
Name:EDGE, MARK THOMAS (PHD MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:EDGE
Suffix:
Gender:M
Credentials:PHD MD
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Mailing Address - Street 1:620 SUMMIT CROSSING PL
Mailing Address - Street 2:STE 106
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-867-8021
Mailing Address - Fax:704-864-4606
Practice Address - Street 1:620 SUMMIT CROSSING PL
Practice Address - Street 2:STE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2002008902085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D4988OtherMEDCOST
SCN0089DMedicaid
560988142OtherUNITED HEALTHCARE
3616445OtherAETNA HMO
NC89132UHMedicaid
132UHOtherBLUE CROSS BLUE SHIELD
7436626OtherAETNA PPO
801319OtherPARTNERS
P00167818OtherRAILROAD MEDICARE
P00167818OtherRAILROAD MEDICARE
132UHOtherBLUE CROSS BLUE SHIELD