Healthcare Provider Details

I. General information

NPI: 1700696309
Provider Name (Legal Business Name): JACOB HEIDISH PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 FOREST DR STE 300
NEW ALBANY OH
43054-8166
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-6555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.009220RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: