Healthcare Provider Details

I. General information

NPI: 1811954837
Provider Name (Legal Business Name): ERIC C HEASLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 COLONY BOULEVARD SUITE 102
BLAIRSVILLE PA
15717-7971
US

IV. Provider business mailing address

25 COLONY BOULEVARD SUITE 102
BLAIRSVILLE PA
15717-7971
US

V. Phone/Fax

Practice location:
  • Phone: 724-459-9111
  • Fax: 724-459-7856
Mailing address:
  • Phone: 724-459-9111
  • Fax: 724-459-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD066199L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: