1538297940 NPI number — BRIAN J. HEINEMAN, D.O.

Table of content: (NPI 1538297940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538297940 NPI number — BRIAN J. HEINEMAN, D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN J. HEINEMAN, D.O.
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:
BROOKLYN MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1538297940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 527
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52211-0527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-522-7221
Provider Business Mailing Address Fax Number:
641-522-5816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 JACKSON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-522-7221
Provider Business Practice Location Address Fax Number:
641-522-5816
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEINEMAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-522-7221

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0415489 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ6924 . This is a "RAIRLROAD MEDICARE GROUP" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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