Healthcare Provider Details

I. General information

NPI: 1548272289
Provider Name (Legal Business Name): JEFFREY A. HEISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N STATE ST STE 100
GREENFIELD IN
46140-1270
US

IV. Provider business mailing address

PO BOX 129
GREENFIELD IN
46140-0129
US

V. Phone/Fax

Practice location:
  • Phone: 317-462-3255
  • Fax:
Mailing address:
  • Phone: 317-468-6270
  • Fax: 317-468-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01062448A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301080253
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: