Healthcare Provider Details

I. General information

NPI: 1962405787
Provider Name (Legal Business Name): JOHN GEORGE HEISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E 3RD ST
CHATTANOOGA TN
37403-2101
US

IV. Provider business mailing address

900 E 3RD ST
CHATTANOOGA TN
37403-2101
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-5437
  • Fax: 423-778-7507
Mailing address:
  • Phone: 423-778-5437
  • Fax: 423-778-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD25694
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: