1215933346 NPI number — HEEERS, PA

Table of content: (NPI 1215933346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215933346 NPI number — HEEERS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEEERS, PA
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:
SULLIVAN FAMILY MEDICINE 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:
1215933346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1814 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39204-3410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-373-2940
Provider Business Mailing Address Fax Number:
601-373-2720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1814 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39204-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-373-2940
Provider Business Practice Location Address Fax Number:
601-373-2720
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS-SULLIVAN
Authorized Official First Name:
HURSIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER AND PRESIDENT
Authorized Official Telephone Number:
601-373-2940

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  13888 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08236531 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00112110 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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