Provider Demographics
NPI:1720625379
Name:EDGE PEDIATRIC LLC
Entity Type:Organization
Organization Name:EDGE PEDIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:
Authorized Official - Last Name:EGO-OSUALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-501-5797
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20703-0345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7500 HANOVER PKWY STE 203
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2009
Practice Address - Country:US
Practice Address - Phone:301-895-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD532153100Medicaid