=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457375859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 FREDERICK AVE
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-271-6573
-----------------------------------------------------
Fax | 816-271-6572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 N BELT HWY
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-3491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-271-6573
-----------------------------------------------------
Fax | 816-271-6572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, REIMBURSEMENT - ACCOUNTIN
-----------------------------------------------------
Name | DWIGHT CARVELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-273-0473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 00996
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 00711
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW001949
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW000121
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------