Provider Demographics
NPI:1265470660
Name:MEDICAL EDGE HEALTHCARE GROUP PA
Entity Type:Organization
Organization Name:MEDICAL EDGE HEALTHCARE GROUP PA
Other - Org Name:
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:PO BOX 650268
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0268
Mailing Address - Country:US
Mailing Address - Phone:888-238-9671
Mailing Address - Fax:
Practice Address - Street 1:6957 W PLANO PKWY STE 1300
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-1621
Practice Address - Country:US
Practice Address - Phone:972-820-1400
Practice Address - Fax:214-820-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR31452261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200384001Medicaid
TX00Y888Medicare PIN
TX00W835Medicare PIN