Provider Demographics
NPI:1952322901
Name:HEARTLAND INFUSTION THERAPY
Entity Type:Organization
Organization Name:HEARTLAND INFUSTION THERAPY
Other - Org Name:HEARTLAND INSTITUTIONAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GESTRINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-671-2745
Mailing Address - Street 1:415 NE SAINT MARK CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 NE SAINT MARK CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3716
Practice Address - Country:US
Practice Address - Phone:309-671-2745
Practice Address - Fax:309-671-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00930113393336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1470549OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========006Medicaid