Provider Demographics
NPI:1407902638
Name:HEARTLAND HEALTHCARE PC
Entity Type:Organization
Organization Name:HEARTLAND HEALTHCARE PC
Other - Org Name:HEARTLAND HEALTHCARE PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-233-9293
Mailing Address - Street 1:327 S.9TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4111
Mailing Address - Country:US
Mailing Address - Phone:770-233-9293
Mailing Address - Fax:770-233-0998
Practice Address - Street 1:327 S.9TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4111
Practice Address - Country:US
Practice Address - Phone:770-233-9293
Practice Address - Fax:770-233-0998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044231173000000X
GA031590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00828055GMedicaid
GA00828055FMedicaid
GA11BDRTSMedicare ID - Type UnspecifiedMEDICAL SERVICES
GA00828055FMedicaid