Provider Demographics
NPI:1407948607
Name:HERITCH, ANDREW JON (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JON
Last Name:HERITCH
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 1:3116 N DRIES LN
Mailing Address - Street 2:#201
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-686-1147
Mailing Address - Fax:309-686-1185
Practice Address - Street 1:3116 N DRIES LN
Practice Address - Street 2:#201
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604
Practice Address - Country:US
Practice Address - Phone:309-686-1147
Practice Address - Fax:309-686-1185
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1044602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
W24235Medicare UPIN
K20748Medicare ID - Type Unspecified