Provider Demographics
NPI:1124108550
Name:MEDICAL EDGE HEALTHCARE GROUP PA
Entity type:Organization
Organization Name:MEDICAL EDGE HEALTHCARE GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIGHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:972-739-3001
Mailing Address - Street 1:PO BOX 650268
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15800 DOOLEY RD
Practice Address - Street 2:STE 120
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4284
Practice Address - Country:US
Practice Address - Phone:972-788-0592
Practice Address - Fax:972-788-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336H0001X, 3336C0004X
TX252553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4548864OtherOTHER ID NUMBER
PH0582Medicare PIN
TXPH0759Medicare PIN
1208280010Medicare NSC