Healthcare Provider Details

I. General information

NPI: 1205966645
Provider Name (Legal Business Name): HEARTLAND FAMILY PHYSICAINS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 E JACKSON BLVD
JACKSON MO
63755-2907
US

IV. Provider business mailing address

2130 E JACKSON BLVD
JACKSON MO
63755-2907
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-3115
  • Fax: 573-243-4700
Mailing address:
  • Phone: 573-243-3115
  • Fax: 573-243-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMDR7D79
License Number StateMO

VIII. Authorized Official

Name: DR. RAMIRO ICAZA
Title or Position: ADMINSTRATOR
Credential: M.D.
Phone: 57352433115