Provider Demographics
NPI:1336172766
Name:HEARTLAND SURGERY LLC
Entity Type:Organization
Organization Name:HEARTLAND SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:O
Authorized Official - Last Name:DEMATTEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-993-3221
Mailing Address - Street 1:3402 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6477
Mailing Address - Country:US
Mailing Address - Phone:618-993-3221
Mailing Address - Fax:
Practice Address - Street 1:3402 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6477
Practice Address - Country:US
Practice Address - Phone:618-993-3221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC48095Medicare UPIN
IL752960Medicare ID - Type Unspecified