Provider Demographics
NPI:1013136787
Name:HERITAGE INTER-MED, PLLC
Entity Type:Organization
Organization Name:HERITAGE INTER-MED, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:CEDRIC
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-299-0003
Mailing Address - Street 1:1121 N JOE WILSON RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-1430
Mailing Address - Country:US
Mailing Address - Phone:972-299-0003
Mailing Address - Fax:972-299-0004
Practice Address - Street 1:1121 N JOE WILSON RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-1430
Practice Address - Country:US
Practice Address - Phone:972-299-0003
Practice Address - Fax:972-299-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
TXL0008261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203079301Medicaid
TX392541OtherWELLCARE
TXDQ8950OtherRAILROAD MEDICARE
TX0158180352OtherSECURE HORIZONS
TX7809231OtherAETNA
TX0A0026Medicare PIN
TX196391001Medicaid