Provider Demographics
NPI:1912927351
Name:HEARTLAND MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:HEARTLAND MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BENEDICTA
Authorized Official - Middle Name:
Authorized Official - Last Name:UMORU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-416-9005
Mailing Address - Street 1:PO BOX 2015
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-0215
Mailing Address - Country:US
Mailing Address - Phone:618-355-9970
Mailing Address - Fax:618-355-9972
Practice Address - Street 1:5032 N ILLINOIS ST
Practice Address - Street 2:SUITE B
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3415
Practice Address - Country:US
Practice Address - Phone:618-416-9005
Practice Address - Fax:618-641-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD7462OtherRR MEDICARE
IL036100162Medicaid
IL08232145OtherBCBS
IL036100162Medicaid
IL08232145OtherBCBS
210779Medicare PIN