Provider Demographics
NPI: | 1639122021 |
---|---|
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: | M |
Authorized Official - Last Name: | HEIGHTEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 972-739-3001 |
Mailing Address - Street 1: | 9229 LYNDON B JOHNSON FWY STE 250 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75243-4403 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-739-3001 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 9229 LYNDON B JOHNSON FWY STE 250 |
Practice Address - Street 2: | |
Practice Address - City: | DALLAS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75243-4403 |
Practice Address - Country: | US |
Practice Address - Phone: | 972-739-3001 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-18 |
Last Update Date: | 2011-09-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 261QR0200X | Ambulatory Health Care Facilities | Clinic/Center | Radiology | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 081500301 | Medicaid | |
TX | 081500302 | Medicaid | |
TX | 200384001 | Medicaid | |
TX | 0046AZ | Other | BCBS |
TX | 0099BH | Other | BCBS |
TX | 186985102 | Medicaid | |
TX | 081500315 | Medicaid | |
TX | 081500316 | Medicaid | |
TX | 00516N | Other | BCBS |
TX | 186985101 | Medicaid | |
TX | 186985103 | Medicaid | |
TX | 0099BH | Medicare PIN | |
TX | 00X840 | Medicare PIN | |
TX | 0099BH | Other | BCBS |
TX | 081500316 | Medicaid | |
TX | CN8341 | Medicare PIN | |
TX | DA7577 | Medicare PIN | |
TX | 0046AZ | Other | BCBS |
TX | 200384001 | Medicaid | |
TX | DD1816 | Medicare PIN | |
TX | DB5501 | Medicare PIN | |
TX | 00516N | Other | BCBS |
TX | 186985102 | Medicaid | |
TX | 00X744 | Medicare PIN |