Provider Demographics
NPI:1689762114
Name:HEIDELBAUGH, JOEL J (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:J
Last Name:HEIDELBAUGH
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 1:700 KMS PLACE
Mailing Address - Street 2:3621 S STATE ST
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:200 ARNET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-482-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074459207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4138431Medicaid
MIH00354Medicare UPIN
MI4138431Medicaid