Provider Demographics
NPI:1669585766
Name:HEARTLAND PHYSICIAN SERVICES, LLC
Entity type:Organization
Organization Name:HEARTLAND PHYSICIAN SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-941-9030
Mailing Address - Street 1:1004 CARONDELET DR
Mailing Address - Street 2:STE 300A
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4801
Mailing Address - Country:US
Mailing Address - Phone:816-941-9030
Mailing Address - Fax:816-941-3866
Practice Address - Street 1:1004 CARONDELET DR
Practice Address - Street 2:STE 300A
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4801
Practice Address - Country:US
Practice Address - Phone:816-941-9030
Practice Address - Fax:816-941-3866
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALIENT PHYSICIAN GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4728OtherMEDICARE PTAN
MOM220000Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER