Provider Demographics
NPI:1134450828
Name:HEALING EDGE MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:HEALING EDGE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:AGNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:860-978-8825
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-0152
Mailing Address - Country:US
Mailing Address - Phone:860-978-8825
Mailing Address - Fax:
Practice Address - Street 1:29 KRIPES RD
Practice Address - Street 2:SUITE M
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9669
Practice Address - Country:US
Practice Address - Phone:860-413-3883
Practice Address - Fax:860-413-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036511207P00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3097037Medicaid
ILJ13195OtherMEDICARE
IL3097037Medicaid