Provider Demographics
NPI:1902943541
Name:EDGE, FRED CLAYTON (DC,MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:CLAYTON
Last Name:EDGE
Suffix:
Gender:M
Credentials:DC,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:PA
Mailing Address - Zip Code:15431-2050
Mailing Address - Country:US
Mailing Address - Phone:724-628-6677
Mailing Address - Fax:724-628-4611
Practice Address - Street 1:1829 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:PA
Practice Address - Zip Code:15431-2050
Practice Address - Country:US
Practice Address - Phone:724-628-6677
Practice Address - Fax:724-628-4611
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001569L111N00000X
PAMD039571L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB36299Medicare UPIN
098060Medicare ID - Type Unspecified