Provider Demographics
NPI:1407892102
Name:HEENAN, GEORGE L (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:L
Last Name:HEENAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NILES ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-429-5000
Mailing Address - Fax:269-429-2598
Practice Address - Street 1:2500 NILES ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-429-5000
Practice Address - Fax:269-429-2598
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGH040763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A73867Medicare UPIN
N75800004Medicare ID - Type Unspecified