Provider Demographics
NPI:1730492695
Name:MEDICAL EDGE HEALTHCARE GROUP PA
Entity Type:Organization
Organization Name:MEDICAL EDGE HEALTHCARE GROUP PA
Other - Org Name:COPPELL FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:972-739-3001
Mailing Address - Street 1:580 S DENTON TAP RD STE 123
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4099
Mailing Address - Country:US
Mailing Address - Phone:972-462-0762
Mailing Address - Fax:972-393-2133
Practice Address - Street 1:580 S DENTON TAP RD STE 123
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4099
Practice Address - Country:US
Practice Address - Phone:972-462-0762
Practice Address - Fax:972-393-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1208280028Medicare NSC