=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912345331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDGE SPINE & JOINT MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2013
-----------------------------------------------------
Last Update Date | 04/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 S MAIN ST SUITE 102
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-837-2112
-----------------------------------------------------
Fax | 724-691-0864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 S MAIN ST SUITE 102
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-837-2112
-----------------------------------------------------
Fax | 724-691-0864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARL CURTIS EDGE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 724-837-2112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | SP011376
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------