Provider Demographics
NPI:1679623631
Name:HEARTLAND DIGESTIVE DISEASE CENTER, LLC
Entity Type:Organization
Organization Name:HEARTLAND DIGESTIVE DISEASE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KASHIF
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-234-8866
Mailing Address - Street 1:2406 RING RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7940
Mailing Address - Country:US
Mailing Address - Phone:270-234-8866
Mailing Address - Fax:270-234-1355
Practice Address - Street 1:2406 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7940
Practice Address - Country:US
Practice Address - Phone:270-234-8866
Practice Address - Fax:270-234-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935926Medicaid
KY1151619OtherPASSPORT GROUP NUMBER
KY1151619OtherPASSPORT GROUP NUMBER