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General NPI Number Information
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NPI Number | 1003899766
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Entity Type | Individual
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Provider Name | MARK THOMAS EDGE PHD MD
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Gender | Male
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Dates
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Enumeration Date | 11/26/2005
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Last Update Date | 08/23/2010
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Provider Practice Location Address
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Address Line | 620 SUMMIT CROSSING PL STE 106
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City | GASTONIA
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State | NC
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Zip | 28054
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Country | US
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Telephone | 704-867-8021
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Fax | 704-864-4606
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Provider Business Mailing Address
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Address Line | 620 SUMMIT CROSSING PL STE 106
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City | GASTONIA
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State | NC
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Zip | 28054
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Country | US
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Telephone | 704-867-8021
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Fax | 704-864-4606
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | 200200890
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 200200890
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License Number State | NC
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