1386685642 NPI number — DR. LAURA LYNN HEIMBACK-GRAHAM MD

Table of content: (NPI 1619735636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386685642 NPI number — DR. LAURA LYNN HEIMBACK-GRAHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEIMBACK-GRAHAM
Provider First Name:
LAURA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1386685642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10744
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33757-8744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-532-0002
Provider Business Mailing Address Fax Number:
727-266-4928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10330 N DALE MABRY HWY STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33618-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-963-7788
Provider Business Practice Location Address Fax Number:
813-443-8149
Provider Enumeration Date:
06/09/2006

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: 208000000X , with the licence number:  ME112872 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000500480005 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1211500 . This is a "IHA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000500480004 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0065758-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08047000068 . This is a "FIDELIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 040426002037 . This is a "FIDELIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0019433420001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00850591 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00010074902 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".




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