Healthcare Provider Details

I. General information

NPI: 1659400976
Provider Name (Legal Business Name): MARK H HEINICKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 W BROADWAY STE 217
LOUISVILLE KY
40202-2114
US

IV. Provider business mailing address

332 W BROADWAY STE 217
LOUISVILLE KY
40202-2114
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-2063
  • Fax:
Mailing address:
  • Phone: 502-589-2063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number21176
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: