Basic Information
| Provider Information | |||||||||
| NPI: | 1073613147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGE MEDICAL SUPPLY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 BARTLETT BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328116428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072060040 | ||||||||
| FaxNumber: | 4072060010 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 E RUSK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035410220 | ||||||||
| FaxNumber: | 9035410440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEROCARE HOLDINGS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 158217413 | 05 | TX | MEDICAID | 158127403 | 05 | TX | MEDICAID |