Provider Demographics
NPI:1457638645
Name:HERITAGE INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:HERITAGE INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOL
Authorized Official - Middle Name:JIMENEZ
Authorized Official - Last Name:GAZZINGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-435-0380
Mailing Address - Street 1:305 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-7471
Mailing Address - Country:US
Mailing Address - Phone:919-435-0380
Mailing Address - Fax:
Practice Address - Street 1:2824 ROGERS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3895
Practice Address - Country:US
Practice Address - Phone:919-435-0380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200701946174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912424Medicaid
2073917Medicare PIN
G30866Medicare UPIN