Provider Demographics
NPI:1295818169
Name:HERITAGE MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:HERITAGE MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:STAUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-255-2620
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:222 22ND AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1852
Practice Address - Country:US
Practice Address - Phone:629-255-3486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
005167OtherCERTIFICATE OF RECOGNITIO