Provider Demographics
NPI:1699797142
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:MD
Authorized Official - Phone:972-739-3001
Mailing Address - Street 1:1645 N TOWN EAST BLVD STE 503
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4147
Mailing Address - Country:US
Mailing Address - Phone:972-686-3901
Mailing Address - Fax:972-686-3985
Practice Address - Street 1:1645 N TOWN EAST BLVD STE 503
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4147
Practice Address - Country:US
Practice Address - Phone:972-686-3901
Practice Address - Fax:972-686-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454865Medicare Oscar/Certification