Provider Demographics
NPI:1073873303
Name:OSTEOPATHIC INTERNAL MEDICINE
Entity Type:Organization
Organization Name:OSTEOPATHIC INTERNAL MEDICINE
Other - Org Name:PLAZA 38 MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-964-1508
Mailing Address - Street 1:5626 OBERLIN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 W 38TH ST
Practice Address - Street 2:1
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-2004
Practice Address - Country:US
Practice Address - Phone:814-868-5481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-21
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003106L332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site