Healthcare Provider Details

I. General information

NPI: 1508965682
Provider Name (Legal Business Name): HEARTLAND MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N BROAD ST
NEW TAZEWELL TN
37825-6600
US

IV. Provider business mailing address

309 N BROAD ST
NEW TAZEWELL TN
37825-6600
US

V. Phone/Fax

Practice location:
  • Phone: 423-626-7297
  • Fax: 423-851-4704
Mailing address:
  • Phone: 423-626-7297
  • Fax: 423-851-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAT G FUGATE
Title or Position: CREDENTIALING
Credential:
Phone: 423-626-7297