MEDICARE: DR. RON R HIEMSTRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME115467	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	14T4Y	OTHER	FLORIDA BLUE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	114638	OTHER	BLUE CROSS MO
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558374454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RON R HIEMSTRA MD

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 400
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-2051
Country	:	US
Telephone Number	:	305-500-2027
Fax Number	:	305-500-2155

Provider Business Practice Location Address
First Line	:	3854 BRITTON PLZ
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-1406
Country	:	US
Telephone Number	:	813-837-2814
Fax Number	:	866-853-2860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	12/17/2021

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