Provider Demographics
NPI:1659472991
Name:HEIDTMAN, EDWARD P (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:HEIDTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HALTON ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607
Mailing Address - Country:US
Mailing Address - Phone:864-382-4000
Mailing Address - Fax:
Practice Address - Street 1:213 HALTON ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-382-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17346207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG49467Medicare UPIN
SC8157Medicare ID - Type Unspecified