Provider Demographics
NPI:1578215422
Name:HERITAGE MEDICAL GROUP
Entity Type:Organization
Organization Name:HERITAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-816-4071
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-1105
Mailing Address - Country:US
Mailing Address - Phone:662-816-4071
Mailing Address - Fax:
Practice Address - Street 1:300 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5463
Practice Address - Country:US
Practice Address - Phone:662-816-4071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy