Healthcare Provider Details

I. General information

NPI: 1912092388
Provider Name (Legal Business Name): SAMUEL RODNEY HEISER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 WESTFIELD RD STE 120
NOBLESVILLE IN
46060-1443
US

IV. Provider business mailing address

PO BOX 843022
KANSAS CITY MO
64184-3022
US

V. Phone/Fax

Practice location:
  • Phone: 317-776-8748
  • Fax: 317-773-0314
Mailing address:
  • Phone: 317-770-6900
  • Fax: 317-770-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01040362A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: