1154869378 NPI number — LAUREN R. HECKHAUS PA-C

Table of content: RAVEN CHANCE (NPI 1558927046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154869378 NPI number — LAUREN R. HECKHAUS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HECKHAUS
Provider First Name:
LAUREN
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1154869378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 THOMAS JOHNSON CT SUITE C
Provider Second Line Business Mailing Address:
INTERNAL MEDICINE SPECIALISTS OF FREDERICK
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-668-9393
Provider Business Mailing Address Fax Number:
301-668-4480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 W FREDERICK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALKERSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21793-8230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-846-6336
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2017

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: 363A00000X , with the licence number:  C0006357 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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