Provider Demographics
NPI:1922814474
Name:EDGE MEDICAL LLC
Entity type:Organization
Organization Name:EDGE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-884-0835
Mailing Address - Street 1:2640 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6704
Mailing Address - Country:US
Mailing Address - Phone:208-884-0835
Mailing Address - Fax:208-884-4794
Practice Address - Street 1:2640 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6704
Practice Address - Country:US
Practice Address - Phone:208-884-0835
Practice Address - Fax:208-884-4794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty