1053413740 NPI number — HEARTLAND PEDIATRIC CLINIC

Table of content: (NPI 1053413740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053413740 NPI number — HEARTLAND PEDIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND PEDIATRIC CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053413740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1866
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-8066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-993-5274
Provider Business Mailing Address Fax Number:
618-993-0639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W DEYOUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-993-5274
Provider Business Practice Location Address Fax Number:
618-999-0639
Provider Enumeration Date:
09/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
618-993-5274

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)