Provider Demographics
NPI:1689764763
Name:HEARTLAND SURGICAL ASSISTANTS, INC
Entity Type:Organization
Organization Name:HEARTLAND SURGICAL ASSISTANTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:863-381-7632
Mailing Address - Street 1:5112 LAKE DEESON WOODS CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-7638
Mailing Address - Country:US
Mailing Address - Phone:863-381-7632
Mailing Address - Fax:863-606-5713
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-381-7647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA4132OtherRAILROAD MEDICARE
FLX1592OtherBCBS
FLDA4132OtherRAILROAD MEDICARE
FLX1592OtherBCBS