Provider Demographics
NPI:1659398188
Name:HEUCKEROTH, ROBERT O (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:O
Last Name:HEUCKEROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9234
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA - GASTROENTEROLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3247
Practice Address - Fax:215-590-3606
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-10-21
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Provider Licenses
StateLicense IDTaxonomies
MO1047392080P0206X
PAMD4496842080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS126902Medicaid
MO103810165Medicaid
LA430653611Medicaid
MO103810165Medicaid
LA430653611Medicaid