Healthcare Provider Details

I. General information

NPI: 1053413740
Provider Name (Legal Business Name): HEARTLAND PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W DEYOUNG ST
MARION IL
62959-1630
US

IV. Provider business mailing address

PO BOX 1866
MARION IL
62959-8066
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-5274
  • Fax: 618-999-0639
Mailing address:
  • Phone: 618-993-5274
  • Fax: 618-993-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS ALBERTO LOPEZ
Title or Position: PRESIDENT/PHYSICIAN
Credential: M.D.
Phone: 618-993-5274