Provider Demographics
NPI:1790987238
Name:HEARTS SOUTH, PC
Entity Type:Organization
Organization Name:HEARTS SOUTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TRIMNEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-5672
Mailing Address - Street 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3001
Mailing Address - Country:US
Mailing Address - Phone:334-793-5672
Mailing Address - Fax:334-794-0378
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:SUITE 403
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-793-5672
Practice Address - Fax:334-794-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207RC0000X207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529301920Medicaid
ALF166Medicare ID - Type UnspecifiedGROUP MEDICARE #