=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477749539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHLAND FAMILY PRACTICE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 09/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 NE 9TH ST
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57042-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-256-3548
-----------------------------------------------------
Fax | 605-256-6808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 NE 9TH ST
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57042-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-256-3548
-----------------------------------------------------
Fax | 605-256-6808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BERNARD F HEILMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 605-256-3548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0263
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------