Healthcare Provider Details

I. General information

NPI: 1316496383
Provider Name (Legal Business Name): MOUNTAINS EDGE MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 2ND ST
RICHLAND CENTER WI
53581
US

IV. Provider business mailing address

2660 CRIMSON CANYON DR STE 130
LAS VEGAS NV
89128-0846
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6321
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60688815
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0057605
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66303
License Number StateWI

VIII. Authorized Official

Name: MATTHEW PAPPY
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 405-740-5017