Healthcare Provider Details

I. General information

NPI: 1124157441
Provider Name (Legal Business Name): RICHARD THOMAS HEIMBECKER P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR SUITE 200
LAWRENCEVILLE GA
30046-3367
US

IV. Provider business mailing address

PO BOX 930223
ATLANTA GA
31193-0223
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-3500
  • Fax: 678-312-3529
Mailing address:
  • Phone: 470-325-0100
  • Fax: 470-325-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: