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NPI Code Detail

MEDICARE: EDGE-MD ILLINOIS, PLLC

MEDICARE: EDGE-MD ILLINOIS, PLLC
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
1207Q00000XFamily Medicine PhysicianN0318TX

General Provider Information

NPI Number : 1285034728
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDGE-MD ILLINOIS, PLLC
Provider Business Mailing Address
First Line : 2022 REGIONAL MEDICAL DR
Second Line : SUITE 1315
City : WHARTON
State : TX
Zip : 77488-7231
Country : US
Telephone Number : 979-532-2000
Fax Number : 979-532-2008
Provider Business Practice Location Address
First Line : 2304 W ILLINOIS AVE
Second Line :
City : DALLAS
State : TX
Zip : 75224-1638
Country : US
Telephone Number : 214-337-7200
Fax Number : 214-337-7206
Authorized Official
Title or Position : OWNER/MD
Name : DR. NATHAN P. NGUYEN
Credential : MD
Telephone Number : 979-532-2000
Provider Enumeration Date : 09/03/2014
Last Update Date : 01/13/2015

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