Healthcare Provider Details

I. General information

NPI: 1316998305
Provider Name (Legal Business Name): HERITAGE MEDICAL ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 4TH ST
PEABODY KS
66866-1103
US

IV. Provider business mailing address

11881 SW 47TH TER
TOWANDA KS
67144-9264
US

V. Phone/Fax

Practice location:
  • Phone: 620-983-2171
  • Fax: 620-983-2575
Mailing address:
  • Phone: 316-778-2050
  • Fax: 316-778-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-25153
License Number StateKS

VIII. Authorized Official

Name: DR. RANDOLPH RICHARD WHITELY
Title or Position: DIRECTOR
Credential: M.D.
Phone: 620-983-2171