Provider Demographics
NPI:1114742178
Name:HEALING EDGE MEDICAL GROUP OR PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:HEALING EDGE MEDICAL GROUP OR PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-499-3165
Mailing Address - Street 1:329 S OYSTER BAY RD STE 2059
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E HUNTINGTON DR STE 203
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1022
Practice Address - Country:US
Practice Address - Phone:615-499-3165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty