Provider Demographics
NPI:1821070970
Name:HEIDELBERGER, EDWIN (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:HEIDELBERGER
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1442
Mailing Address - Country:US
Mailing Address - Phone:716-592-3635
Mailing Address - Fax:716-592-2929
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-592-3635
Practice Address - Fax:716-592-2929
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190805207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY190805OtherWORKERS COMP
NY00020006701OtherUNIVERA
NY0145550001OtherDMERC
NY01458795Medicaid
NY0003153OtherGHI
NY0408931AOAOtherINDEPENDENT HEALTH
NY000523119009OtherBCBS
NY190805OtherWORKERS COMP
NYF71919Medicare UPIN