Provider Demographics
NPI:1235112731
Name:HEIB, ANDREW J (CCSP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:HEIB
Suffix:
Gender:M
Credentials:CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 E CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4421
Mailing Address - Country:US
Mailing Address - Phone:269-324-0100
Mailing Address - Fax:
Practice Address - Street 1:2225 E CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4421
Practice Address - Country:US
Practice Address - Phone:269-324-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6816111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5489001OtherMEDICARE PTAN
MI269464414Medicaid
MIU22897Medicare UPIN