Provider Demographics
NPI:1407803927
Name:HERITAGE MEDICAL GROUP
Entity Type:Organization
Organization Name:HERITAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARZIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:NAMEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-443-5588
Mailing Address - Street 1:PO BOX 3148
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48333-3148
Mailing Address - Country:US
Mailing Address - Phone:586-443-5588
Mailing Address - Fax:586-443-5538
Practice Address - Street 1:22301 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2619
Practice Address - Country:US
Practice Address - Phone:586-443-5588
Practice Address - Fax:586-443-5538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N56920Medicare PIN