Provider Demographics
NPI:1497222343
Name:EDGE-MD HOLDING PLLC
Entity Type:Organization
Organization Name:EDGE-MD HOLDING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-920-3107
Mailing Address - Street 1:1200 W WALNUT HILL LN STE 1300
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3050
Mailing Address - Country:US
Mailing Address - Phone:972-514-1672
Mailing Address - Fax:
Practice Address - Street 1:1200 W WALNUT HILL LN STE 1300
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-3050
Practice Address - Country:US
Practice Address - Phone:972-514-1672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory