Healthcare Provider Details

I. General information

NPI: 1003899766
Provider Name (Legal Business Name): MARK THOMAS EDGE PHD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2005
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SUMMIT CROSSING PL STE 106
GASTONIA NC
28054
US

IV. Provider business mailing address

620 SUMMIT CROSSING PL STE 106
GASTONIA NC
28054
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-8021
  • Fax: 704-864-4606
Mailing address:
  • Phone: 704-867-8021
  • Fax: 704-864-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number200200890
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200200890
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: