Provider Demographics
NPI:1740207539
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 1:399 MELROSE DR STE A
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-4415
Mailing Address - Country:US
Mailing Address - Phone:972-234-2000
Mailing Address - Fax:972-421-4676
Practice Address - Street 1:399 MELROSE DR STE A
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4415
Practice Address - Country:US
Practice Address - Phone:972-234-2000
Practice Address - Fax:972-421-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL05688261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081500316Medicaid
TX00X840Medicare PIN