MEDICARE: MEDICAL EDGE HEALTHCARE GROUP PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336H0001X	Home Infusion Therapy Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	25255	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4548864	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1124108550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL EDGE HEALTHCARE GROUP PA

Provider Business Mailing Address
First Line	:	PO BOX 650268
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0268
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15800 DOOLEY RD
Second Line	:	STE 120
City	:	ADDISON
State	:	TX
Zip	:	75001-4284
Country	:	US
Telephone Number	:	972-788-0592
Fax Number	:	972-788-0697

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLAY HEIGHTEN
Credential	:	RPH
Telephone Number	:	972-739-3001

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	06/01/2010

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