Provider Demographics
NPI:1922060656
Name:CEDAREDGE DOCTORS OFFICE PC
Entity Type:Organization
Organization Name:CEDAREDGE DOCTORS OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-856-4111
Mailing Address - Street 1:255 S GRAND MESA DR
Mailing Address - Street 2:
Mailing Address - City:CEDAREDGE
Mailing Address - State:CO
Mailing Address - Zip Code:81413-3822
Mailing Address - Country:US
Mailing Address - Phone:970-856-4111
Mailing Address - Fax:970-856-4114
Practice Address - Street 1:255 S GRAND MESA DR
Practice Address - Street 2:
Practice Address - City:CEDAREDGE
Practice Address - State:CO
Practice Address - Zip Code:81413-3822
Practice Address - Country:US
Practice Address - Phone:970-856-4111
Practice Address - Fax:970-856-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42323797Medicaid
COCE39326OtherBLUE CROSS BLUE SHIELD
COCE39326OtherBLUE CROSS BLUE SHIELD
COCE39326OtherBLUE CROSS BLUE SHIELD
CO4703170001Medicare NSC
CODE0667Medicare ID - Type UnspecifiedRAILROAD MEDICARE