1356526305 NPI number — HERITAGE MEDICAL GROUP, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356526305 NPI number — HERITAGE MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE MEDICAL GROUP, PC
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:
1356526305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 PENNSYLVANIA AVENUE
Provider Second Line Business Mailing Address:
HERITAGE MEDICAL GROUP, PC
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-288-3883
Provider Business Mailing Address Fax Number:
770-288-3885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 PENNSYLVANIA AVENUE
Provider Second Line Business Practice Location Address:
HERITAGE MEDICAL GROUP, PC
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-288-3883
Provider Business Practice Location Address Fax Number:
770-288-3885
Provider Enumeration Date:
01/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OSINUGA
Authorized Official First Name:
OLADAYO
Authorized Official Middle Name:
ADISA
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
770-288-3883

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  057161 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 51703 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2200X , with the licence number: RN178172NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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