Provider Demographics
NPI:1689628208
Name:HEIDRICH, GEORGE III (RN)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:HEIDRICH
Suffix:III
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5014 PICCADILLY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-2014
Mailing Address - Country:US
Mailing Address - Phone:608-235-1766
Mailing Address - Fax:
Practice Address - Street 1:5014 PICCADILLY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-2014
Practice Address - Country:US
Practice Address - Phone:608-235-1766
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77912163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI398600Medicaid