Provider Demographics
NPI:1215028899
Name:RIETZ, HEATHER M (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:RIETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 VIRGINIA WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7541
Mailing Address - Country:US
Mailing Address - Phone:615-221-4474
Mailing Address - Fax:615-234-3774
Practice Address - Street 1:5301 VIRGINIA WAY
Practice Address - Street 2:STE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7541
Practice Address - Country:US
Practice Address - Phone:615-221-4474
Practice Address - Fax:615-234-3774
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36151207ZP0102X
TN34155207ZP0105X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000000016015OtherTLC TENNCARE
GA10057952OtherAMERIGROUP MEDICAID GACMO
NC5902767Medicaid
GA629419657AMedicaid
AL009964100Medicaid
TN100033069OtherPHP TENNCARE
GA335777OtherWELLCARE GA MEDICAID CMO
TN119451OtherUNISONTENNCARE
TN3150369OtherBLUE CROSS
TN3852383Medicaid
KY64028533Medicaid
H15137Medicare UPIN
GA629419657AMedicaid
TN3852383Medicare ID - Type Unspecified
NC5902767Medicaid