1811973324 NPI number — DR. CYNTHIA LEE HECKMAN-DAVIS M.D.

Table of content: DR. CYNTHIA LEE HECKMAN-DAVIS M.D. (NPI 1811973324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811973324 NPI number — DR. CYNTHIA LEE HECKMAN-DAVIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HECKMAN-DAVIS
Provider First Name:
CYNTHIA
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1811973324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N. MICHIGAN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-784-8244
Provider Business Practice Location Address Fax Number:
574-784-8632
Provider Enumeration Date:
12/16/2005

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: 207Q00000X , with the licence number:  01033081A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000391881 . This is a "BCBS BMG IRELAND" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 080018191 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000085185 . This is a "BCBS BMG LAKEVILLE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100089660 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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