Provider Demographics
NPI:1285034728
Name:EDGE-MD ILLINOIS, PLLC
Entity Type:Organization
Organization Name:EDGE-MD ILLINOIS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-532-2000
Mailing Address - Street 1:2022 REGIONAL MEDICAL DR
Mailing Address - Street 2:SUITE 1315
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-7231
Mailing Address - Country:US
Mailing Address - Phone:979-532-2000
Mailing Address - Fax:979-532-2008
Practice Address - Street 1:2304 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-1638
Practice Address - Country:US
Practice Address - Phone:214-337-7200
Practice Address - Fax:214-337-7206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty