Basic Information
| Provider Information | |||||||||
| NPI: | 1780825794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL EDGE HEALTHCARE GROUP PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KYLE HOOGENDOORN DPM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 12TH AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | 8178775665 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 12TH AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | 8178775665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2009 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | HEIGHTEN | ||||||||
| AuthorizedOfficialFirstName: | CLAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9727393001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.