Provider Demographics
NPI:1407867807
Name:HERITAGE OBSTETRICS & GYNECOLGY CLINIC OF NM PA
Entity Type:Organization
Organization Name:HERITAGE OBSTETRICS & GYNECOLGY CLINIC OF NM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-840-4010
Mailing Address - Street 1:606 BRUNSON DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4947
Mailing Address - Country:US
Mailing Address - Phone:662-840-4010
Mailing Address - Fax:662-840-9038
Practice Address - Street 1:606 BRUNSON DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4947
Practice Address - Country:US
Practice Address - Phone:662-840-4010
Practice Address - Fax:662-840-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207V00000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05453772Medicaid
MSC03247Medicare ID - Type Unspecified
MSE51009Medicare UPIN