Provider Demographics
NPI:1639493448
Name:HERITAGE ANESTHESIA PC
Entity Type:Organization
Organization Name:HERITAGE ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:212-856-5624
Mailing Address - Street 1:8109 LINKSVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2737
Mailing Address - Country:US
Mailing Address - Phone:214-856-5624
Mailing Address - Fax:
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:214-856-5624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCO1451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184989002Medicaid