Provider Demographics
NPI:1457425217
Name:HERITAGE PHYSICIAN GROUP
Entity Type:Organization
Organization Name:HERITAGE PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBO SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-627-1816
Mailing Address - Street 1:PO BOX 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903
Mailing Address - Country:US
Mailing Address - Phone:501-627-1800
Mailing Address - Fax:501-627-1899
Practice Address - Street 1:100 MCGOWAN COURT
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-627-1800
Practice Address - Fax:501-627-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4096670003Medicare NSC