Provider Demographics
NPI:1245390160
Name:HEARTLAND REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:HEARTLAND REGIONAL MEDICAL CENTER
Other - Org Name:LAKESIDE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-271-6611
Mailing Address - Street 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-1351
Mailing Address - Fax:816-271-1355
Practice Address - Street 1:902 N RIVERSIDE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2559
Practice Address - Country:US
Practice Address - Phone:816-271-1351
Practice Address - Fax:816-271-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD116083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO540156809Medicaid