=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114969201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNATHON CURTIS EDGE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 03/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 E PARRISH AVE BLDG E SUITE 205
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-852-1645
-----------------------------------------------------
Fax | 270-852-1646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 E PARRISH AVE BLDG E SUITE 205
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-852-1645
-----------------------------------------------------
Fax | 270-852-1646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 39536
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------