Healthcare Provider Details

I. General information

NPI: 1750372777
Provider Name (Legal Business Name): MARK DOUGLAS EDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N PARK TRL STE B
STOCKBRIDGE GA
30281
US

IV. Provider business mailing address

1355 PEACHTREE ST NE STE 1600
ATLANTA GA
30309-3276
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-0909
  • Fax: 770-507-1919
Mailing address:
  • Phone: 678-223-7774
  • Fax: 678-223-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number48041
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: