Healthcare Provider Details

I. General information

NPI: 1164656559
Provider Name (Legal Business Name): JOEL THOMAS HEITMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD DEPT OF
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

150 BERTRAND DR
FRANKLIN TN
37064-8308
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6031
  • Fax:
Mailing address:
  • Phone: 810-964-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number52155
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35125154
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number47753
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301095035
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2019042401
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01074617A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: