Healthcare Provider Details

I. General information

NPI: 1952364051
Provider Name (Legal Business Name): CHARLES KIRBY HERITAGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST MIAMI VALLEY HOSPITAL
DAYTON OH
45409-2722
US

IV. Provider business mailing address

1 WYOMING ST MIAMI VALLEY HOSPITAL
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2912
  • Fax: 937-208-4515
Mailing address:
  • Phone: 937-208-2912
  • Fax: 937-208-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35050784
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: