1245255322 NPI number — CHAD R HEATWOLE MD

Table of content: CHAD R HEATWOLE MD (NPI 1245255322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245255322 NPI number — CHAD R HEATWOLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEATWOLE
Provider First Name:
CHAD
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1245255322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 278984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14627-8984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-275-2559
Provider Business Mailing Address Fax Number:
585-273-1255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14642-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-275-2559
Provider Business Practice Location Address Fax Number:
585-273-1255
Provider Enumeration Date:
07/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  230605 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P010230605 . This is a "BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02740063 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDJ059 . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P020230605 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".