Healthcare Provider Details

I. General information

NPI: 1124108550
Provider Name (Legal Business Name): MEDICAL EDGE HEALTHCARE GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15800 DOOLEY RD STE 120
ADDISON TX
75001-4284
US

IV. Provider business mailing address

PO BOX 650268
DALLAS TX
75265-0268
US

V. Phone/Fax

Practice location:
  • Phone: 972-788-0592
  • Fax: 972-788-0697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25255
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CLAY HEIGHTEN
Title or Position: PRESIDENT
Credential: RPH
Phone: 972-739-3001