Provider Demographics
NPI:1669681581
Name:HERITAGE INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:HERITAGE INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:STJERNHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-564-0450
Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:SUITE A535
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-564-0450
Mailing Address - Fax:719-564-1659
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE A535
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-0450
Practice Address - Fax:719-564-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCN4621OtherRAILROAD MEDICARE
CO04021622Medicaid
COCN4621OtherRAILROAD MEDICARE