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 | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 261QR0200X | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
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 |
