Provider Demographics
NPI:1700996030
Name:HETTICK INTERNAL MEDICINE
Entity Type:Organization
Organization Name:HETTICK INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HETTICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-541-1400
Mailing Address - Street 1:4319 LONDONDERRY RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5318
Mailing Address - Country:US
Mailing Address - Phone:717-541-1400
Mailing Address - Fax:717-541-8080
Practice Address - Street 1:4319 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5318
Practice Address - Country:US
Practice Address - Phone:717-541-1400
Practice Address - Fax:717-541-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047575L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG23931Medicare UPIN
PA892435Medicare PIN