Provider Demographics
NPI:1578505129
Name:HEARTFELT PHYSICIAN SERVICES, PLLC
Entity Type:Organization
Organization Name:HEARTFELT PHYSICIAN SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:KATHLEENE
Authorized Official - Last Name:MOTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-552-1327
Mailing Address - Street 1:20245 W 12 MILE RD
Mailing Address - Street 2:STE 120
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5409
Mailing Address - Country:US
Mailing Address - Phone:248-552-1327
Mailing Address - Fax:586-859-5729
Practice Address - Street 1:20245 W 12 MILE RD
Practice Address - Street 2:STE 120
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5409
Practice Address - Country:US
Practice Address - Phone:248-552-1327
Practice Address - Fax:586-859-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407599208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P47750001Medicare PIN