Provider Demographics
NPI:1235284928
Name:GRENADA LAKE INPATIENT MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:GRENADA LAKE INPATIENT MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARTSILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-227-7172
Mailing Address - Street 1:PO BOX 52007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0007
Mailing Address - Country:US
Mailing Address - Phone:678-397-0060
Mailing Address - Fax:678-397-0065
Practice Address - Street 1:960 J K AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5230
Practice Address - Country:US
Practice Address - Phone:662-227-7492
Practice Address - Fax:662-227-7541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherTIN