Provider Demographics
NPI:1356526305
Name:HERITAGE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:HERITAGE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLADAYO
Authorized Official - Middle Name:ADISA
Authorized Official - Last Name:OSINUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-288-3883
Mailing Address - Street 1:1010 PENNSYLVANIA AVENUE
Mailing Address - Street 2:HERITAGE MEDICAL GROUP, PC
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253
Mailing Address - Country:US
Mailing Address - Phone:770-288-3883
Mailing Address - Fax:770-288-3885
Practice Address - Street 1:1010 PENNSYLVANIA AVENUE
Practice Address - Street 2:HERITAGE MEDICAL GROUP, PC
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253
Practice Address - Country:US
Practice Address - Phone:770-288-3883
Practice Address - Fax:770-288-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057161207Q00000X
GARN178172NP363LA2200X
GA51703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BO7921340OtherDEA
H62947Medicare UPIN