Provider Demographics
NPI:1003982547
Name:HERITAGE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:HERITAGE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:MISKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-475-1999
Mailing Address - Street 1:131 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5409
Mailing Address - Country:US
Mailing Address - Phone:401-475-1999
Mailing Address - Fax:401-475-6932
Practice Address - Street 1:131 BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5409
Practice Address - Country:US
Practice Address - Phone:401-475-1999
Practice Address - Fax:401-475-6932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD 10350207R00000X
CTCT 0816213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty